- Patient Story – Tara Robinson’s Blood Clot Survival Story
- Pulmonary Embolism
- Etiology, Risk Factors, and Pathophysiology
- Signs and Symptoms
- Management and Classification
- Nonpharmacologic Options
- Pharmacologic Options
- Pharmacist’s Role
- How to Prevent Deadly Blood Clots in Pregnancy
- Causes of Deep Vein Thrombosis in Pregnancy
- Recognizing DVT Symptoms in Pregnancy
- Prevent Pregnancy Blood Clots
- Blood Clots During Pregnancy: Symptoms, Treatments and Prevention
- Anticoagulation therapy for serious blood clots during pregnancy
- Deep Vein Thrombosis (DVT): Management and Treatment
- Blood Clots
- What are blood clots?
- Deep Vein Thrombosis
- Risk Factors
- Living With Deep Vein Thrombosis
- Links to Other Information About Deep Vein Thrombosis
Patient Story – Tara Robinson’s Blood Clot Survival Story
The personal story below is intended for informational purposes only. The National Blood Clot Alliance (NBCA) holds the rights to all content that appears on its website. The use by another organization or online group of any content on NBCA’s website, including the patient stories that appear here, does not imply that NBCA is connected to these other organizations or groups or condones or endorses their work. Please contact [email protected] with questions about this matter.
Tara Robison was startled at age 20 by 21 blood clots in her lungs. She was misdiagnosed at first, but her persistence in seeking further care saved her life.
In June 2010, I felt a pain in the right side of my upper chest that I thought at first was just gas pain. I woke up the next morning feeling as if I was in the middle of a battlefield, because I was fighting attempts to sleep, because chest pain was interrupting my sleep, and I even had sit up to sleep. Certain moves worsened the pinching that I felt in my chest.
Nurses I knew told me that it was probably just a pulled muscle or my gallbladder. I felt miserable, so I left work early to go to the nearest medical center. I had a cough, stuffy nose, and this stupid pinching pain in my chest that hurt every time I coughed o breathed in. After waiting hours at the medical center, the doctor listened to my lungs, took an X-ray of my chest, and had me move my arms.
He sent me home with a diagnosis of a possible pulled muscle in my chest, and he ordered an X-ray that showed nothing significant. He noticed some congestion in my lungs, but said it was not serious. Little did I know at this time that my symptoms were signaling blood clots in my lungs.
Four days later, I finally went to the Emergency Room (ER) because I felt even more miserable. It took fewer than five seconds after the doctor told me that a CAT scan showed that I had 21 blood clots in both of my lungs for tears to flow down my face, for the ER to become a blur, and the thoughts in my mind blotted out any noise. I felt terrified.
Blood clots? They can be fatal. I’m going to die. I’m going to die. Mommy, help me! Why won’t they do something? What’s going to happen? What does this mean? I have college to finish, the perfect man to marry, a family to create.
Ultrasounds were done on my legs to try to find a source for my pulmonary emboli (PEs), although there was no evidence of a deep vein thrombosis (DVT).
I felt my mom’s kisses on my forehead as I stared out into the hallway. My mom looked at me and with the bravest voice told me, “You’re going to be okay, baby.” How did she know? What would help me? Minutes after the doctor left, I w as surrounded by nurses. Pinch! I felt an IV placed in my arm. Very rapidly, I was placed on blood thinners and told that I had to stay in the hospital. Pinch! I received a shot of blood thinners in my stomach that burned like a bee sting, and I was told I would have a bruise, since blood thinners may cause one. I was on injected heparin for ten days and Coumadin® for six months.
I also tested positive for factor V Leiden. After one night of bed rest and sleeplessness, my primary physician came. He was extremely shocked by what was happening to me, and told me that he was relieved that I went to the ER, because my age (20) led healthcare professionals to first diagnose a pulled muscle or a cold. From that I have learned: Rule #1: Listen to your body. Rule #2: Do not stop fighting.
Looking back, I waited way too long to go to the ER. I am so thankful that my body was able to keep up and keep me safe.
My life has changed. I work harder for what I want and know I deserve. I value each and every interaction I have in this world. When you realize you are lucky to be alive, it changes things. It changes the way you say I love you; it changes the way you smile, the way you think, the way you live.
So here I am now writing this story to inform others of the importance of listening to their body. I am grateful and thankful that I am here today to write this story. I was on oral contraceptives when the episode occurred, which added to my risk, and which I have stopped taking. Had I known I had a clotting disorder I never would have taken any oral contraceptives and I believe that women need to be aware of the potential of clotting disorders adding to the risk of blood clots.
Blood clots are terrifying and can develop without any warning signs and be unpredictable in their impact on the body. I will not lie, I wonder what is going on inside my body and if a clot is going to strike again. I need to stay motivated to use as many preventive measures as possible. Stories like mine and the other brave individuals who tell their stories need to be shared. National Blood Clot Alliance is a phenomenal organization and should be utilized for its resources, awareness, and support.
Take Home Messages
- Get care right away in the ER for chest pain or shortness of breath.
- Don’t delay in getting another opinion if your symptoms do not go away.
- Birth control pills pose a risk for blood clots, and an underlying blood clotting disorder increases risk.
- X-rays do not detect lung clots.
- Pulmonary embolism (PE/lung clot) and deep vein thrombosis (DVT/leg clot) are misdiagnosed as something else at times.
What is a pulmonary embolism?
A pulmonary embolism is a blood clot in the lung that occurs when a clot in another part of the body (often the leg or arm) moves through the bloodstream and becomes lodged in the blood vessels of the lung. This restricts blood flow to the lungs, lowers oxygen levels in the lungs and increases blood pressure in the pulmonary arteries.
If a clot develops in a vein and it stays there, it’s called a thrombus. If the clot detaches from the wall of the vein and travels to another part of your body, it’s called an embolus.
Who is at risk of developing a blood clot?
People at risk for developing a blood clot are those who:
- Have been inactive or immobile for long periods of time due to bed rest or surgery.
- Have a personal or family history of a blood clotting disorder, such as deep vein thrombosis (DVT) or pulmonary embolism (PE).
- Have a history of cancer or are receiving chemotherapy.
- Sit for prolonged periods.
People at risk for developing a pulmonary embolism include those who:
- Are inactive for long periods of time while traveling via motor vehicle, train or plane.
- Have a history of heart failure or stroke.
- Are overweight or obese.
- Have recently had trauma or injury to a vein, possibly after a recent surgery, fracture or due to varicose veins.
- Are pregnant or have given birth in the previous 6 weeks.
- Are taking birth control pills (oral contraceptives) or hormone replacement therapy.
- Placement of central venous catheters through the arm or leg If you have any of these risk factors and you have had a blood clot, please talk with your health care provider so steps can be taken to reduce your personal risk.
How serious is a pulmonary embolism?
A pulmonary embolism may dissolve on its own; it is seldom fatal when diagnosed and treated properly. However, if left untreated, it can be serious, leading to other medical complications, including death. A pulmonary embolism can:
- Cause heart damage.
- Be life-threatening, depending on the size of the clot.
What are the symptoms of pulmonary embolism?
Symptoms of pulmonary embolism vary, depending on the severity of the clot. Although most people with a pulmonary embolism experience symptoms, some will not.
Symptoms may include:
- Sudden shortness of breath — whether you’ve been active or at rest.
- Unexplained sharp pain in your chest, arm, shoulder, neck or jaw. The pain may also be similar to symptoms of a heart attack.
- Pale, clammy or bluish-colored skin.
- Rapid heartbeat (pulse).
- Cough with or without bloody sputum (mucus).
- Excessive sweating.
- In some cases, feeling anxious, light-headed, faint or passing out.
It is also possible to have a blood clot and not have any symptoms, so discuss your risk factors with your health care provider. If you have any symptoms of pulmonary embolism, such as those listed above, get medical attention immediately.
If you have any symptoms of pulmonary embolism, get medical attention immediately.
What causes pulmonary embolism?
Pulmonary embolism may occur:
- When blood collects (or “pools”) in a certain part of the body (usually an arm or leg). Pooling of blood usually occurs after long periods of inactivity, such as after surgery or bed rest.
- When veins have been injured, such as from a fracture or surgery (especially in the pelvis, hip, knee or leg).
- As a result of another medical condition, such as cardiovascular disease (including congestive heart failure, atrial fibrillation and heart attack) or stroke.
- When clotting factors in the blood are increased, elevated, or in some cases, lowered. Elevated clotting factors can occur with some types of cancer or in some women taking hormone replacement therapy or birth control pills. Abnormal or low clotting factors may also occur as a result of hereditary conditions.
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US Pharm. 2018;43(7):HS-2-HS12.
ABSTRACT: Pulmonary embolism (PE) is a clot in the lung artery, most often due to deep vein thrombosis. It can be difficult to detect and may result in death. The severity of PE and the patient’s presentation drive treatment selection and the care plan. Massive PE is a medical emergency requiring immediate treatment with thrombolytics, anticoagulants, and/or surgery; nonmassive PE may be treated in an outpatient setting. In patients with this diagnosis, pharmacists have a major role in assessing and monitoring therapy, providing patient and caregiver education, and assisting with prior authorization and procurement in the community.
Venous thromboembolism (VTE) encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE).1 Incidence of PE is difficult to determine as it is complicated to identify and diagnose.2,3 It is estimated that approximately 900,000 people per year have a VTE, up to 30% of whom will die within the first month of diagnosis. Approximately one-quarter of patients with PE will die of sudden death.4 Treatment options include nonpharmacologic or pharmacologic management.
The World Health Organization (WHO) estimates a worldwide incidence of PE of 0.75 to 2.69 per 1,000 individuals per year.5 The CDC estimates a rate of 1 to 2 per 1,000 people per year in the United States alone.4 The mortality rate of acute PE is approximately 7% to 11% and is estimated to cost the United States’ healthcare system $30,000 in the first year after diagnosis.6,7
Etiology, Risk Factors, and Pathophysiology
Patient age and history of VTE are risk factors for the development of VTE, with PE commonly resulting from DVT. A clot in a deep vein can dislodge and travel, entering the right side of the heart and continuing to the pulmonary artery. If the clot blocks blood flow in the pulmonary artery or one of its branches, it is a PE, which can lead to death if not treated.1,8,9 Additional risk factors, typically referred to as Virchow’s Triad, include blood stasis, vascular injury, and hypercoagulability.1 Malignancy, heart failure, pregnancy, postpartum status, obesity, age, smoking, respiratory failure, intensive care, coagulopathy, and hormone replacement therapy/oral contraceptives are also risk factors.6,10,11
Signs and Symptoms
Over 90% of patients present with dyspnea, tachypnea, or chest pain that mimics ischemic angina.1,10 Patients may also have tachycardia.1 Others may present with coughing (20%), syncope (14%), or hemoptysis (7%). Only 5% to 7% of patients will present with “classic” symptoms of PE reported as a triad of shortness of breath, chest pain, and hemoptysis.10
Diagnosis includes electrocardiogram, chest x-ray, echocardiogram, and CT pulmonary angiography (CTA).10,11 A workup may include the following to aid in confirming or excluding PE: D-dimers, biomarkers of myocardial injury and overload, blood gases, clotting tests, and ventilation-perfusion scans. Although two scoring systems, the Wells Score and the Revised Geneva Score, are available to assess the likelihood of PE, they are not commonly used in practice. Diagnosis is challenging in the presence of other pulmonary comorbidities, such as pneumonia, chronic obstructive pulmonary disease, asthma, or chronic lung disease with fibrosis.10 The complexity of PE presentation frequently results in a diagnosis of exclusion.10,11 In most cases, it is recommended to begin parenteral anticoagulation for suspicion of PE while the workup is in progress.12
Management and Classification
Management includes pharmacologic therapy with thrombolytics and anticoagulation, or nonpharmacologic management, and is stratified into initial, long-term, and extended treatments. Patient-specific treatment is guided by signs and symptoms, bleeding risk, and comorbidities.11,13,14 Goals of treatment include clot resolution and decreased risk of recurrence. Additional goals include decreased risk of consequences of PE, such as death, pulmonary hypertension, and impaired functional outcomes.13
Initial Phase: The aim in the initial phase is to reduce mortality and recurrence in the 5 to 10 days after presentation. Treatment options for initial-phase management include thrombolytics, parenteral anticoagulants, oral anticoagulants, and nonpharmacologic interventions.14
Long-Term Treatment: Long-term treatment is given for at least 3 months with either parenteral or oral anticoagulants. In patients whose PE was provoked, either by surgery or another risk factor, treatment is recommended for 3 months. Patients with unprovoked PE should be treated for 3 months, with reevaluation at 3 months to determine the risks versus the benefits of continuing therapy. In patients with low or moderate bleeding risk, the 2016 Chest Guideline and Expert Panel Report on antithrombotic therapy for VTE recommends extended therapy at this time, whereas patients with high bleeding risk may not be candidates for continuing anticoagulation after 3 months.14
Extended Anticoagulation: Extended anticoagulation is treatment with anticoagulants beyond the first 3 to 6 months, with no anticipated discontinuation date.12,14,15 Patients in whom thrombosis was triggered by nonsurgical risk factors or who have persistent risk factors are at higher risk for recurrence than those with postoperative thrombosis. Patients with unprovoked PE with low-to-moderate bleeding risk should be considered for extended treatment and reevaluated frequently for continuation. Patients with a second unprovoked PE may require extended therapy if their bleeding risk is low or moderate. In all patients with active cancer and cancer-associated PE, extended therapy should be continued, regardless of bleeding risk.14
PE severity is classified as massive (high risk), submassive (intermediate risk), and nonmassive (low risk).10
Massive PE (high risk): Massive PE is defined as having no pulse, a heart rate less than 40 beats per minute, and signs of shock or continuous hypotension. In this case, sustained hypotension cannot be due to dysrhythmias, hypovolemia, sepsis, or left ventricular dysfunction, and is defined as systolic blood pressure (SBP) below 90 mmHg for at least 15 minutes, or SBP below 100 mmHg in a patient with a hypertension diagnosis, or at least a 40% reduction in baseline SBP.13 Patients with massive PE may require immediate resuscitation and management in an intensive-care setting.11 Initial treatment is based on the patient’s vital signs and signs of clinical shock and may include isotonic IV fluids along with other appropriate critical-care management.11,13
Initial-phase treatment with thrombolytics followed by parenteral anticoagulation is recommended for these patients, and considerations may also include catheter-directed thrombolysis or surgical embolectomy if thrombolytics are contraindicated.13,14
Submassive PE (moderate risk): Submassive PE consists of SBP at least 90 mmHg, with some signs of cardiopulmonary stress, such as right ventricular dysfunction or myocardial necrosis defined as elevation in troponin I or T.13 Submassive PE presents with end organ damage, but patients are hemodynamically stable. These patients may also present with cardiac ischemia and altered mental status.11
Thrombolytics may be considered for initial-phase treatment in this patient population if there is clinical evidence of developing hemodynamic instability or worsening prognosis. Risks of bleeding should be weighed against benefits of thrombolysis.13 Other pharmacologic options include parenteral or oral anticoagulants.12 If hypotension develops after anticoagulation, thrombolytic therapy may be revisited at that time.14
Nonmassive PE (low risk): Nonmassive PE may not show any clinical or hemodynamic signs or right ventricular dysfunction based on echocardiogram or biomarkers.13 Patients with low-risk (nonmassive) PE have no end organ damage or hemodynamic instability.11
These patients are candidates for initial-phase treatment with anticoagulants as outpatients and continued long-term therapy.12,14
Nonpharmacologic treatment is considered when there is a high risk of bleeding and thrombolytic therapy is contraindicated.14 These treatments include catheter-directed therapies, embolectomy, suction, or inferior vena cava filter (IVCF) placement.
Catheter-Directed Therapies: Catheter-directed therapies include ultrasound, use of pressurized saline injection, or catheter-led mechanical disruption of thrombi.16 Delivery of catheter-directed therapy may involve off-label use of thrombolytics, used in smaller doses than are used in systemic thrombolysis, thereby lowering the risk of bleeding. The 2016 antithrombotic guideline recommends administration of systemic thrombolytic therapy over catheter-directed therapies in patients who do not have high bleeding risk, given that this therapy has a higher level of evidence.14
Embolectomy: Embolectomy can be done either via catheter or surgically and should be considered if a patient has hemodynamic instability and if thrombolytic therapy is contraindicated.14
Suctioning: Suctioning may remove a thrombus (thrombectomy) or thrombi fragments.16
IVCF Placement: IVCF placement indications vary according to different medical societies and guidelines, although there is consensus to utilize IVCF in patients with acute VTE who are not candidates for anticoagulation.17 The 2016 antithrombotic guideline recommends against the use of IVCF in acute PE patients who are treated with anticoagulants.14 Although a systematic review and meta-analysis found an association of IVCF placement and lower PE risk, these studies were of low-to-moderate quality and showed a higher DVT risk with no effect on mortality.18
Pharmacologic treatment options, including drug dosages and contraindications, are listed in Table 1.
Thrombolytic: Patients with massive PE who are not at high risk of bleeding are candidates for systemic thrombolytic therapy with alteplase, also known as tissue plasminogen activator (tPA).14 Additionally, patients who deteriorate after receiving initial anticoagulation should be considered for alteplase. Twenty-four hours after thrombolytic therapy, studies showed lowering of pulmonary artery pressure, increasing arterial oxygenation, and resolving perfusion scan defects in patients.12 Alteplase, the only FDA-approved thrombolytic treatment for massive PE, converts plasminogen to plasmin in the coagulation cascade, which results in fibrinolysis. It is administered intravenously via a peripheral vein as a 2-hour infusion.12,19
Parenteral Anticoagulation: Parenteral anticoagulants may be used alone in patients who are not candidates for tPA, or are initiated at the end of the tPA infusion.12,19 These medications prevent further clot formation and work in the coagulation cascade to enhance the body’s ability to dissolve existing clots.11 Options include enoxaparin, dalteparin, fondaparinux, and unfractionated heparin (UFH).
Subcutaneous low molecular weight heparins (LMWH) (enoxaparin and dalteparin) and fondaparinux are effective parenteral anticoagulants for the treatment of PE with dalteparin indicated for extended treatment.12, 20-22 LMWH is preferred if the patient also presents with proximal DVT, in patients with cancer-associated PE, and in pregnancy or pregnancy risks.12,14 LMWH is administered by SC injection and does not require activated partial thromboplastin time (aPTT) laboratory monitoring. Patients treated with enoxaparin should be evaluated for appropriate kidney function because the drug is renally excreted.20 Fondaparinux is a synthetic antithrombotic agent with specific Factor Xa activity, which is also indicated for PE treatment. Like LMWH, it is a subcutaneous injection administered once daily and dosed based on patient weight.22,23 Although fondaparinux has a long half-life and no reversal agent, it is an alternative for patients with a history of heparin-induced thrombocytopenia because it does not cross-react with heparin-induced antibodies.11 Other parenteral agents may be available for off-label treatment of PE in patients with heparin-induced thrombocytopenia (HIT).
Intravenous UFH: Intravenous UFH is the treatment of choice for patients at high risk of bleeding or who are likely to undergo intervention, thrombolysis, or embolectomy, owing to its short half-life.11 It is also the preferred agent in patients with renal dysfunction, obese patients, or those with a recent bleeding history.24 UFH is administered as a continuous infusion via a peripheral vein and requires aPTT laboratory monitoring and dose titration during the infusion to ensure efficacy.25 Platelet count is monitored since UFH is associated with the highest incidence of HIT. In fact, patients treated with UFH are 8 to 10 times more likely to develop HIT than those treated with LMWH.
Noncancer patients are transitioned to oral anticoagulants for long-term treatment upon discharge.14 If a patient is to be transitioned to warfarin, overlap or “bridging” with a parenteral anticoagulant is continued for at least 5 days and until an international normalized ratio (INR) test is at least 2.0 for 24 hours.24,26
Oral Anticoagulation: The 2016 antithrombotic guidelines recommend oral anticoagulation with direct oral anticoagulants (DOACs): direct thrombin inhibitor dabigatran, or factor Xa inhibitors edoxaban, rivaroxaban, or apixaban in low-risk patients without cancer.14,27-32 These agents may be started after initial treatment with thrombolytics and parenteral anticoagulants in massive and submassive PE, or as initial treatment in nonmassive PE.
Dabigatran and edoxaban are approved for long-term VTE treatment after 5 to 10 days of parenteral anticoagulation.14,29,30 Dabigatran, rivaroxaban, and apixaban have been studied in extended treatment and are as efficacious as warfarin with less bleeding.14 Apixaban and rivaroxaban doses are decreased for extended therapy.31-34
Warfarin may be considered in patients with renal disease, coronary artery disease, poor adherence, history of gastrointestinal bleeding, or noncancer patients who are not candidates for DOACs.14 With bridging from other anticoagulants, warfarin is dosed once daily, and the dose is adjusted based on INR results, with a goal INR of 2.0 to 3.0.12,14,26
Aspirin: Three studies evaluated the use of aspirin for extended treatment. The authors concluded that aspirin reduced the overall risk of recurrence of unprovoked PE without increased risk of bleeding when compared with placebo.35 Aspirin may be considered for extended treatment in patients who are stopping anticoagulation and have no contraindications to aspirin.14
Pharmacists play an important role in the management of PE. Patient-specific drug selection and dosing are important to maximize therapy and minimize adverse events. Patient risk factors, comorbidities, and organ function are factors in selecting the appropriate agent at the appropriate dose for the appropriate duration. Drug-drug and drug-nutrient interactions are also important in selecting medications and doses. Owing to the risk of bleeding and other drug misadventures, patient and caregiver education that stresses correct administration, storage, adherence, and when to call a healthcare provider are crucial to preventing complications and identifying recurrences. The community or ambulatory pharmacist may be first-line in triaging these occurrences.
In addition to counseling and patient selection, instruction in injection technique may be necessary. Disease-state education focuses on risk reduction, including medication therapy reviews to identify medications that may increase the risk of PE. Pharmacists also have a role in facilitating third-party payment, such as prior authorizations or suggesting alternative therapies while payment approval is pending. Many institutions possess an anticoagulation clinic to manage and monitor this patient population. Pharmacists have also been involved in evaluating cost-effectiveness of these therapies for managed care and other organizations.36,37
PE is the result of a clot in the pulmonary artery or one of its branches. If untreated, PE can result in death. Goals of initial treatment include clot resolution; long-term and extended treatment aim to decrease the risk of recurrence. Additional goals include decreased risk of consequences of PE, such as death, pulmonary hypertension, and impaired functional outcomes. Treatment selection is patient-specific and depends on symptoms, bleeding risk, and comorbidities. Treatment options include nonpharmacologic therapies and pharmacologic therapy with thrombolytics and anticoagulants.
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How to Prevent Deadly Blood Clots in Pregnancy
Causes of Deep Vein Thrombosis in Pregnancy
Why is there an increased risk of deep vein thrombosis when a woman is expecting? “A lot of physiological changes take place during pregnancy,” said Pamela Berens, MD, professor of obstetrics and gynecology at The University of Texas Medical School in Houston. One is the compression in the pelvis from the baby. “There are also changes in clotting factors in the blood that begin early in pregnancy and last until a woman is six weeks post-partum,” she added.
Pregnancy hormones play a role. “There’s a lot of estrogen circulating during pregnancy, and estrogen increases the risk of blood clots,” Dr. Roshan said. Women on birth control pills that contain estrogen are at a similar increased risk of DVT. Roshan added that women with genetic clotting disorders, called thrombophilias, are at an even higher risk for deep vein thrombosis in pregnancy.
Other factors that can further raise your chances of developing deep vein thrombosis in pregnancy include:
- Being 35 or older
- Previous pregnancy blood clot or clot outside of pregnancy
- Being overweight
- Having a cesarean delivery (C-section).
Recognizing DVT Symptoms in Pregnancy
You have enough on your mind without stressing over deep vein thrombosis. So instead of worrying, be aware of the symptoms. Most pregnancy blood clots occur in the legs. “So watch for tenderness in the calf and thighs, pain in the back of your calf, and swelling, particularly if it is on one side more than the other,” Roshan said.
Pregnancy blood clots that have moved to the heart or lungs can cause chest pain and/or shortness of breath. This signals an even more serious situation.
“If you have any signs of DVT, seek medical attention right away,” Roshan said. A healthcare professional will be able to easily see if your discomfort is due to a pregnancy blood clot by performing an ultrasound of the affected area.
If you indeed have DVT, the treatment will be a blood thinner, usually enoxaparin (Lovenox), which is safe during pregnancy. “We treat the clot with a therapeutic dose for a few months and then lower it to a prophylactic (preventive) dose,” he said.
For pregnant women with a prior history of DVT or pregnancy blood clots or with a genetic thrombophilia, doctors usually prescribe blood thinners in the lower preventive dose. “We usually monitor women taking blood thinners throughout their pregnancies because as the pregnancy progresses, they sometimes need higher doses,” Roshan said. “And for women with a family history of DVT but no personal past history, we sometimes prescribe baby aspirin and tell them to be particularly cautious about symptoms.”
Prevent Pregnancy Blood Clots
By virtue of being pregnant or in the post-partum period, expectant women and new moms are at an increased risk for deep vein thrombosis, so you can’t eliminate the risk completely. But there are some steps to reduce your risk of blood clots:
Keep moving. “If you are overweight and sedentary, it will affect your blood flow and increase your risk for deep vein thrombosis in pregnancy,” Dr. Berens said. “So stay active and maintain a healthy weight.” If you have to be on bed rest due to an injury or complication in your pregnancy, your doctor may prescribe blood thinners as a precautionary measure.
Get up during travel. “Flying alone is a risk factor for DVT, so pregnant women who fly are definitely at increased risk,” Berens said. If you have to fly, get up and move around every hour or two and do ankle roll exercises while you sit. “And do the same thing if you go on a long car or bus ride,” she added.
Wear compression stockings. Because they help improve circulation and reduce swelling in the legs, compression stockings can help lower your risk of deep vein thrombosis in pregnancy, Roshan said.
Drink lots of water. Staying hydrated during pregnancy helps prevent clots by keeping the blood from getting too thick, Roshan said.
Overall, err on the side of caution when it comes to pregnancy blood clots, for your sake and the sake of your baby. “Deep vein thrombosis in pregnancy can be life-threatening, so if you see any signs, don’t hesitate to go to your doctor to get checked,” Roshan said.
Blood Clots During Pregnancy: Symptoms, Treatments and Prevention
Mar 08, 2018
March is Bleeding Disorders Awareness Month, which makes it a perfect time to discuss blood clots during pregnancy. During pregnancy, increased estrogen levels, lack of activity due to bed rest or general discomfort, and all of the fun things that come along with the changes happening within your body put you at a higher risk for developing blood clots.
About Blood Clots During Pregnancy
According to the American Pregnancy Association, only one or two pregnant women out of every 1,000 will develop a blood clot. These women are most likely to develop the blood clot during their first three months or within the first six weeks after giving birth. Although they are rare, blood clots can be extremely dangerous and even fatal to both you and your baby.
Blood clots during pregnancy usually develop deep within the leg or pelvic region and are known as a condition called deep vein thrombosis (DVT). When DVT is caught in the early stages, treatment can begin to safely break down the clot. Without treatment, the blood clot can break apart into large clumps that can travel to the lungs, known as a pulmonary embolism, or to the placenta. A pulmonary embolism can be fatal to both mom and baby, while a clot that travels to the placenta can cut off blood supply to your baby.
Complications Caused by Blood Clots During Pregnancy
- A blood clot that travels to the placenta
- A blood clot that travels to the lungs (pulmonary embolism)
- Heart attack
Risks Factors For Blood Clots
- A personal or family history of DVT
- Smoking or exposure to secondhand smoke
- Being over the age of 35
- Being overweight
- Traveling long distances while pregnant
- Being sedentary for long periods
- Being pregnant with twins, triplets or other multiples
- Having had a caesarian section in the past
- High blood pressure
Symptoms of Blood Clots
Although blood clots are unlikely, there are few symptoms or warning signs that may indicate the presence of a blood clot. If you are experiencing any of these symptoms, it is important for you to contact your doctor or midwife immediately. Symptoms of blood clots during pregnancy include:
- Swelling or pain in one leg
- Pain behind the knee and an area that may feel hot to the touch
- Pain in one leg that gets worse when you walk
- Veins that seem to be larger than normal
Treatment and Prevention of Blood Clots During Pregnancy
Treatment for blood clots usually includes preventive medications. These medications, known as blood thinners, stop existing clots from getting bigger and help prevent any new clots from forming.
How to Reduce Your Risk of Developing a Blood Clot
- Stay active
- Be sure to stretch your legs on long car rides at least every hour
- Decrease the amount of salt in your diet
- Avoid sitting with your legs crossed
- If you are on bed rest, avoid placing pillows under your knees, and ask your doctor for exercises that can help increase the blood flow in your legs
- Avoid cigarette smoke
Be sure to make your provider aware if you have any symptoms or even risk factors of developing a blood clot. This allows your doctor to closely monitor your progress and to be proactive in preventive care. If at any time during your pregnancy you notice any changes that have no explanation, please be sure to communicate that to your medical team.
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Anticoagulation therapy for serious blood clots during pregnancy
Pregnant women are more susceptible than non-pregnant women to forming blood clots in their veins (venous thrombosis). When these clots occur in the deep leg veins, the clot can break up and fragments (emboli) move to the lungs where they may block the blood flow to the lungs (pulmonary embolism). This can have serious consequences. Anticoagulants are used to treat clots and are given to pregnant women with increased susceptibility to clotting. These medications thin the blood to reduce the risk of the further thrombosis and reduce the risk of pulmonary embolism. An important complication of treatment is haemorrhage. During pregnancy heparin is the most common anticoagulant used, either the older unfractionated heparin (UFH) or the newer low molecular weight heparin (LMWH). Neither of these cross the placenta, and both have been shown to be safe during pregnancy, whereas there are concerns that warfarin may affect the fetus. LMWH has been shown to be more effective than UFH outside pregnancy.
In this review we planned to compare these two types of heparin in pregnancy for their ability to reduce clotting and their safety. We could not find any randomised controlled trials for inclusion in the review.
This means that we do not have any evidence from randomised controlled trials on the effectiveness of anticoagulation for deep vein thrombosis in pregnancy, and the effectiveness of LMWH compared to UFH. There is a need for further studies in this area.
Deep Vein Thrombosis (DVT): Management and Treatment
A DVT may make it harder for you to get around at first. You should slowly return to your normal activities. If your legs feel swollen or heavy, lie in bed with your heels propped up about 5 to 6 inches. This helps improve circulation and decreases swelling.
- Exercise your lower leg muscles if you are sitting still for long periods of time.
- Stand up and walk for a few minutes every hour while awake.
- Don’t wear tight-fitting clothing that could decrease the circulation in your legs.
- Wear compression stockings as recommended by your doctor.
- Avoid activities that may cause a serious injury.
What treatments are available for patients with a DVT?
Patients with a DVT may need to be treated in the hospital. Others may be able to have outpatient treatment.
Treatments include medications, compression stockings and elevating the affected leg. If the blood clot is extensive, you may need more invasive testing and treatment. The main goals of treatment are to:
- Stop the clot from getting bigger
- Prevent the clot from breaking off in your vein and moving to your lungs
- Reduce the risk of another blood clot
- Prevent long-term complications from the blood clot (chronic venous insufficiency).
Important Information About Medications
- Take your medications exactly as your doctor tells you to.
- Have blood tests as directed by your doctor and keep all scheduled laboratory appointments.
- Do not stop or start taking any medication (including nonprescription/over-the-counter medications and supplements) without asking your doctor.
- Talk to your doctor about your diet. You may need to make changes, depending on the medication you take.
Treatment for a DVT can include:
Anticoagulants (“blood thinners”). This type of medication makes it harder for your blood to clot. Anticoagulants also stop clots from getting bigger and prevent blood clots from moving. Anticoagulants do not destroy clots. Your body may naturally dissolve a clot, but sometimes clots do not completely disappear.
There are different types of anticoagulants. Your doctor will talk to you about the best type of medication for you.
If you need to take an anticoagulant, you may only need to take it for 3 to 6 months. But, your treatment time may be different if:
- You have had clots before, your treatment time may be longer.
- You are being treated for another illness (such as cancer), you may need to take an anticoagulant as long as your risk of a clot is higher.
The most common side effect of anticoagulants is bleeding. You should call your doctor right away if you notice that you bruise or bleed easily while taking this medication.
You will likely need to wear graduated compression stockings to get rid of leg swelling. The swelling is often because the valves in the leg veins are damaged or the vein is blocked by the DVT.Most compression stockings are worn just below the knee. These stockings are tight at the ankle and become more loose as they go up the leg. This causes gentle pressure (compression) on your leg.
DVT Treatment Procedures
Vena cava filters are used when you cannot take medications to thin your blood or if you have blood clots while taking this type of medication. The filter prevents blood clots from moving from the vein in your legs to the lung (pulmonary embolism). The filter is put in place during minor surgery. It is inserted through a catheter into a large vein in the groin or neck, then into the vena cava (the largest vein in the body). Once in place, the filter catches clots as they move through the body. This treatment helps prevent a pulmonary embolism, but does not prevent the formation of more clots.
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What are blood clots?
Blood clots are semi-solid masses of blood. Normally, blood flows freely through veins and arteries. Some blood clotting, or coagulation, is necessary and normal. Blood clotting helps stop bleeding if you are cut or injured. However, when too much clotting occurs, it can cause serious complications.
When a blood clot forms, it can be stationary (called a thrombosis) and block blood flow or break loose (called an embolism) and travel to various parts of the body.
There are two different types of clots:
- Arterial clots are those that form in the arteries. Once arterial clots form, they cause symptoms immediately. Because this type of clot prevents oxygen from reaching vital organs, it can cause a variety of complications like stroke, heart attack, paralysis and intense pain.
- Venous clots are those that form in the veins. Venous clots typically form slowly over a period of time. Symptoms of venous clots gradually become more noticeable.
Blood clots can occur in many different parts of the body, each area having different symptoms:
- Legs and arms: Symptoms of blood clots in the legs and arms vary and may include pain or cramping, swelling, tenderness, warmth to the touch and bluish- or red-colored skin. Clots that occur in larger veins are called deep vein thrombosis (DVT). Blood clots can also occur in smaller, more superficial (closer to the skin) veins.
- Heart: Common symptoms for blood clots in the heart include pain in the chest and left arm, sweating and difficulty breathing.
- Lungs: The most common symptoms include shortness of breath or difficulty breathing, chest pain and cough. Other symptoms that may or may not appear are sweating, discolored skin, swelling in the legs, irregular heartbeat and/or pulse and dizziness.
- Brain: Patients with blood clots in their brains can experience problems with their vision or speech, seizures and general weakness.
- Abdomen: Symptoms of abdominal blood clots can include severe abdominal pain, nausea, vomiting and diarrhea and/or bloody stools.
A blood clot can be life-threatening depending on the location and severity.
Deep Vein Thrombosis
Other Names for Deep Vein Thrombosis
- Blood clot in the leg.
- Venous thrombosis.
- Venous thromboembolism (VTE). This term is used for both deep vein thrombosis and pulmonary embolism.
Blood clots can form in your body’s deep veins if:
- A vein’s inner lining is damaged. Injuries caused by physical, chemical, or biological factors can damage the veins. Such factors include surgery, serious injuries, inflammation, and immune responses.
- Blood flow is sluggish or slow. Lack of motion can cause sluggish or slow blood flow. This may occur after surgery, if you’re ill and in bed for a long time, or if you’re traveling for a long time.
- Your blood is thicker or more likely to clot than normal. Some inherited conditions (such as factor V Leiden) increase the risk of blood clotting. Hormone therapy or birth control pills also can increase the risk of clotting.
The risk factors for deep vein thrombosis (DVT) include:
- A history of DVT.
- Conditions or factors that make your blood thicker or more likely to clot than normal. Some inherited blood disorders (such as factor V Leiden) will do this. Hormone therapy or birth control pills also increase the risk of clotting.
- Injury to a deep vein from surgery, a broken bone, or other trauma.
- Slow blood flow in a deep vein due to lack of movement. This may occur after surgery, if you’re ill and in bed for a long time, or if you’re traveling for a long time.
- Pregnancy and the first 6 weeks after giving birth.
- Recent or ongoing treatment for cancer.
- A central venous catheter. This is a tube placed in a vein to allow easy access to the bloodstream for medical treatment.
- Older age. Being older than 60 is a risk factor for DVT, although DVT can occur at any age.
- Overweight or obesity.
Your risk for DVT increases if you have more than one of the risk factors listed above.
The signs and symptoms of deep vein thrombosis (DVT) might be related to DVT itself or pulmonary embolism (PE). See your doctor right away if you have signs or symptoms of either condition. Both DVT and PE can cause serious, possibly life-threatening problems if not treated.
Only about half of the people who have DVT have signs and symptoms. These signs and symptoms occur in the leg affected by the deep vein clot. They include:
- Swelling of the leg, or along a vein in the leg
- Pain or tenderness in the leg, which you may feel only when standing or walking
- Increased warmth in the area of the leg that’s swollen or painful
- Red or discolored skin on the leg
Some people aren’t aware of a deep vein clot until they have signs and symptoms of PE. Signs and symptoms of PE include:
- Unexplained shortness of breath
- Pain with deep breathing
- Coughing up blood
Rapid breathing and a fast heart rate also may be signs of PE.
Your doctor will diagnose deep vein thrombosis (DVT) based on your medical history, a physical exam, and test results. He or she will identify your risk factors and rule out other causes of your symptoms.
For some people, DVT might not be diagnosed until after they receive emergency treatment for pulmonary embolism (PE).
To learn about your medical history, your doctor may ask about:
- Your overall health
- Any prescription medicines you’re taking
- Any recent surgeries or injuries you’ve had
- Whether you’ve been treated for cancer
Your doctor will check your legs for signs of DVT, such as swelling or redness. He or she also will check your blood pressure and your heart and lungs.
Your doctor may recommend tests to find out whether you have DVT.
The most common test for diagnosing deep vein blood clots is ultrasound. This test uses sound waves to create pictures of blood flowing through the arteries and veins in the affected leg.
Your doctor also may recommend a D-dimer test or venography (ve-NOG-rah-fee).
A D-dimer test measures a substance in the blood that’s released when a blood clot dissolves. If the test shows high levels of the substance, you may have a deep vein blood clot. If your test results are normal and you have few risk factors, DVT isn’t likely.
Your doctor may suggest venography if an ultrasound doesn’t provide a clear diagnosis. For venography, dye is injected into a vein in the affected leg, which makes the vein visible on an x-ray image. The x-ray will show whether blood flow is slow in the vein, which may suggest a blood clot.
Other tests used to diagnose DVT include magnetic resonance imaging (MRI) and computed tomography (to-MOG-rah-fee), or CT scanning. These tests create pictures of your organs and tissues.
You may need blood tests to check whether you have an inherited blood clotting disorder that can cause DVT. This may be the case if you have repeated blood clots that are not related to another cause. Blood clots in an unusual location (such as the liver, kidney, or brain) also may suggest an inherited clotting disorder.
If your doctor thinks that you have PE, he or she may recommend more tests, such as a lung ventilation perfusion scan (VQ scan). A lung VQ scan shows how well oxygen and blood are flowing to all areas of the lungs.
For more information about diagnosing PE, go to the Health Topics Pulmonary Embolism article.
Doctors treat deep vein thrombosis (DVT) with medicines and other devices and therapies. The main goals of treating DVT are to:
- Stop the blood clot from getting bigger
- Prevent the blood clot from breaking off and moving to your lungs
- Reduce your chance of having another blood clot
Your doctor may prescribe medicines to prevent or treat DVT.
Anticoagulants (AN-te-ko-AG-u-lants) are the most common medicines for treating DVT. They’re also known as blood thinners.
These medicines decrease your blood’s ability to clot. They also stop existing blood clots from getting bigger. However, blood thinners can’t break up blood clots that have already formed. (The body dissolves most blood clots with time.)
Blood thinners can be taken as a pill, an injection under the skin, or through a needle or tube inserted into a vein (called intravenous, or IV, injection).
Warfarin and heparin are two blood thinners used to treat DVT. Warfarin is given in pill form. (Coumadin® is a common brand name for warfarin.) Heparin is given as an injection or through an IV tube. There are different types of heparin; your doctor will discuss the options with you.
Your doctor may treat you with both heparin and warfarin at the same time. Heparin acts quickly, while warfarin takes 2 to 3 days before it starts to work. Once the warfarin starts to work, the heparin is stopped.
Pregnant women are usually treated with just heparin, because warfarin is dangerous during pregnancy.
Treatment for DVT using blood thinners usually lasts for 6 months. The following situations may change the length of treatment:
- If your blood clot occurred after a short-term risk (for example, surgery), your treatment time may be shorter.
- If you’ve had blood clots before, your treatment time may be longer.
- If you have certain other illnesses, such as cancer, you may need to take blood thinners for as long as you have the illness.
The most common side effect of blood thinners is bleeding. Bleeding can happen if the medicine thins your blood too much. This side effect can be life threatening.
Sometimes the bleeding is internal (inside your body). People treated with blood thinners usually have regular blood tests to measure their blood’s ability to clot. These tests are called PT and PTT tests.
These tests also help your doctor make sure you’re taking the right amount of medicine. Call your doctor right away if you have easy bruising or bleeding. These may be signs that your medicines have thinned your blood too much.
These medicines interfere with the blood clotting process. They’re used to treat blood clots in patients who can’t take heparin.
Doctors prescribe these medicines to quickly dissolve large blood clots that cause severe symptoms. Because thrombolytics can cause sudden bleeding, they’re used only in life-threatening situations.
Other Types of Treatment
Vena Cava Filter
If you can’t take blood thinners or they’re not working well, your doctor may recommend a vena cava filter.
The filter is inserted inside a large vein called the vena cava. The filter catches blood clots before they travel to the lungs, which prevents pulmonary embolism. However, the filter doesn’t stop new blood clots from forming.
Graduated Compression Stockings
Graduated compression stockings can reduce leg swelling caused by a blood clot. These stockings are worn on the legs from the arch of the foot to just above or below the knee.
Compression stockings are tight at the ankle and become looser as they go up the leg. This creates gentle pressure up the leg. The pressure keeps blood from pooling and clotting.
There are three types of compression stockings. One type is support pantyhose, which offer the least amount of pressure.
The second type is over-the-counter compression hose. These stockings give a little more pressure than support pantyhose. Over-the-counter compression hose are sold in medical supply stores and pharmacies.
Prescription-strength compression hose offer the greatest amount of pressure. They also are sold in medical supply stores and pharmacies–however, a specially trained person needs to fit you for these stockings.
Talk with your doctor about how long you should wear compression stockings.
You can take steps to prevent deep vein thrombosis (DVT) and pulmonary embolism (PE). If you’re at risk for these conditions:
- See your doctor for regular checkups.
- Take all medicines as your doctor prescribes.
- Get out of bed and move around as soon as possible after surgery or illness (as your doctor recommends). Moving around lowers your chance of developing a blood clot.
- Exercise your lower leg muscles during long trips. This helps prevent blood clots from forming.
If you’ve had DVT or PE before, you can help prevent future blood clots. Follow the steps above and:
- Take all medicines that your doctor prescribes to prevent or treat blood clots.
- Follow up with your doctor for tests and treatment.
- Use compression stockings as your doctor directs to prevent leg swelling.
Contact your doctor at once if you have any signs or symptoms of DVT or PE. For more information, go to “What Are the Signs and Symptoms of Deep Vein Thrombosis?”
The risk of developing DVT while traveling is low. The risk increases if the travel time is longer than 4 hours, or if you have other DVT risk factors.
During long trips, it may help to:
- Walk up and down the aisles of the bus, train, or airplane. If traveling by car, stop about every hour and walk around.
- Move your legs and flex and stretch your feet to improve blood flow in your calves.
- Wear loose and comfortable clothing.
- Drink plenty of fluids and avoid alcohol.
If you have risk factors for DVT, your doctor may advise you to wear compression stockings while traveling, or he or she may suggest that you take a blood-thinning medicine before traveling.
Living With Deep Vein Thrombosis
- Pulmonary Embolism (Health Topics)
- Deep Vein Thrombosis (MedlinePlus)
- Pulmonary Embolism (MedlinePlus)
- Children and Clinical Studies
- Clinical Trials (Health Topics)
- Current Research (ClinicalTrials.gov)
- NHLBI Clinical Trials
- NIH Clinical Research Trials and You (National Institutes of Health)
- ResearchMatch (funded by the National Institutes of Health)
Links to Other Information About Deep Vein Thrombosis
- Pulmonary Embolism (Diseases and Conditions Index)
- Study Finds Ways to Improve Detection of Blood Clots in the Lung (NIH News Release, May 31, 2006)
- Deep Vein Thrombosis (MedlinePlus)
- Pulmonary Embolism (MedlinePlus)
- Current Research (ClinicalTrials.gov)
- NHLBI Pediatric Clinical Trials