Lupine Publishers | Surgery & Case Studies: Open Access Journal
Introduction: In three studies done in Madagascar, venous
thromboembolism mainly affects the female gender. The objective
of this study was to identify the characteristics of this disease at
Hospital University of Gynecology and Obstetrics Befelatanana.
Methods: This is a retrospective descriptive study for four years, from January 2011 to December 2014.
Results: We identified twenty-seven veinous thromboembolism in 42 443 cases (0.06%) of which 15 cases (55%) of deep vein
thrombosis (DVT), 8 cases (30%) of pulmonary embolism and 4 cases (15%) of deep vein thrombosis complicated by pulmonary
embolism. The average age is 37.74 years. The main risk factors are age over 40 years (40.74%), postpartum (40.74%), prolonged
immobilization (25.92%), gynecological cancer (18.51%), pregnancy (18.51%) and menopause (14.81%). All patients with DVT
suffer from unilateral lower limb pain and dyspnea for pulmonary embolism. Enoxaparin relaying by fluindione earlier is our main
cure, and enoxaparin associated with early up constitute preventive treatment. Eleven cases have a favorable outcome. Ten cases
died of pulmonary embolism. The rest has been transferred into specialized services.
Conclusion: The search for risk factors of thromboembolism is the basis of prevention.
Keywords: Anticoagulant; Epidemiology; Evolution; Female; Risk Factor; Venous Thromboembolism; Prevention
Introduction
Venous thromboembolism (VTE) is a unique pathology that
includes two main clinical forms: deep vein thrombosis (DVT) and
pulmonary embolism (PE). The risk factors for the occurrence
of VTE are multiple and often related to hospitalization. Apart
from all the other factors common to both genders, the woman
has particular risk factors such as contraception, pregnancy,
postpartum, uterine myoma, gynecological and obstetrical surgery,
hormone replacement therapy, protocols ovulation stimulation
in the context of medically assisted procreation [1]. Through
its impact on morbidity and mortality and medical costs, VTE
represents a major public health issue. The incidence of DVT and
PE in the general population is respectively about 1 case per 1000
people per year and 0.5 / 1000 people / year [2]. In Madagascar,
three studies were conducted in three different departments that
found an incidence of VTE ranging from 0.07% to 0.97% [3-5]. All
these studies found a female predominance. The main objective
of this study is to determine the characteristics of the VTE in the
University Hospital of Gynecology and Obstetrics of Befelatanana
(CHU GOB).
Method
It is a retrospective descriptive study carried out over a fouryear
period (January 2011 to December 2014), at the University
Hospital Center of Gynecology and Obstetrics in Befelatanana
(CHUGOB). Included in this study are all patients hospitalized at CHU
GOB and presenting with clinical signs of DVT MI and / or PE, with a
high or intermediate clinical probability score for PE. Excludes low
clinical suspicion of PE or presence of diagnosis other than PE and
incomplete, unusable sources. The parameters studied in this study
are sociodemographic parameters, anamnestic parameters, clinical
parameters, paraclinical parameters, the principles of management
and evolution. The results obtained were copied to Microsoft Excel
and then processed on the XLS 6.0 software. They were expressed
on average and as a percentage.
Results
There were 42,443 patients hospitalized at the University
Hospital of Gynecology and Obstetrics Befelatanana from January
1, 2011 to December 31, 2014. Twenty-seven of them had been
identified as having presented an MTEV or 0.06% of which: 15 cases
(55%) of TVPMI, 8 cases (i.e. 30%) of PE and 4 cases (15%) of TVPMI
complicated with PE. The mean age of the patients was 37.74 years
with a standard deviation of 11.86 years; the extreme ages were
18 and 63 years old. Patients between the age group 20 - 30 years
were the most numerous with 9 cases or 33.33%. Patients with 3
and 4 parities were the most numerous with 11 cases (40.74%) of
each. Among the reasons for hospitalization, metrorrhagia ranked
first with 10 cases (37.04%), followed by pelvic pain and infectious
syndrome with 04 cases each (14.82%), followed by dyspnea. 03
cases (i.e. 11.11%), and finally the pain of the lower limbs with 02
cases (i.e. 7.41%) Post-partum, menopause, gynecological cancer,
pregnancy was the most frequently encountered gynecological
and obstetric risk factors with a frequency ranging from 14.81%
to 40.74%. For post-partum, 63.63% (7 out of 11 cases) of MTEV
occurred after cesarean section and 36.37% (4 cases out of 11)
after vaginal delivery. Age greater than or equal to 40 years, bed
rest, heart failure and sedentary lifestyle were the most frequently
encountered medical risk factors accounting respectively for
40.74% of cases (11 cases); 25.63% of cases (7 cases) and 14.82%
of cases (4 cases) for the remains. Patients with only one risk factor
were the most numerous with 33.33% of cases (9 cases). The 17
cases (62.97%) have at least two risk factors. Clinically, out of
twenty-seven cases, 19 (70.37%) had lower limb pain at the time
of diagnosis, followed by the positive HOMANS sign and unilateral
MI edema accounting for 51.85% (14cas) and 48.15% (13 cases).
In contrast, tachycardia and dyspnea were the most representative
signs of PE with 12 cases (44.44%) of each followed by chest pain
and signs of shock in 6 cases (22.22%). Finally, by hemoptysis with
4 cases (14.81%). In the case of TVPMI, according to the WELLS
score, 48.15% of our patients (13 cases) had a high probability;
14.81% (i.e. 4 cases) a moderate probability and 3.70% (i.e. 1 case)
a low clinical probability of TVPMI (Figure 1). According to the
same score, the same frequency of 22.22% (12 cases) represented
the strong and moderate clinical probability of PE (Figure 2). The
MTEV sat on the lower left side in 37.04% of cases (10 cases), in
the lower right in 33.33% of cases (9 cases). Isolated pulmonary
embolism accounted for 29.63% (8 cases). Paraclinically, only
three out of twenty-seven patients (11.11%) were able to assay
the D-Dimer whose value was greater than 500μg / ml. Fifteen
patients out of 19 cases (i.e. 79%) of TVPMI were able to do
Doppler ultrasound of the lower limbs. Of the 15 patients who
underwent ultrasound Doppler ultrasound, the iliac vein was the
most affected with 6 cases (40%), followed by the femoral vein
and popliteal under popliteal with 4 cases of each (26.67%). In
terms of treatment, eight cases (29.63%) benefited from drug
thromboprophylaxis with LMWH and early levee before the MTEV
episode. Note that they were all post-operated. Twenty-two out of
twenty-seven cases (81.48%) received curative doses of LMWH, of
which only 14 cases (or 51.85%) had been relayed to the AVK. No
patients received fibrinolytics or UFH. Ten cases (37.04%) required
respiratory support and vasopressors. Regarding evolution (Figure
3), eleven cases (40.74%) had a favorable evolution; while 10
patients (37.04%) died and 6 (22.22%) transferred to a specialized
department.
Figure 1: Distribution of DVT MI according to the WELLS
score
Figure 2: Distribution of PE according to the WELLS score
Figure 3: Evolution according to the type of MTEV
Discussion
In developed countries, the frequency of VTE was around
85 to 180 per 100,000 women per year [6-7]. In Africa, hospital prevalences ranged from 1.88% to 11.76% [1,8 -9]. In Madagascar,
at the Soavinandriana Hospital Center, the frequency was
0.07% in 2007 [4] and 0.97% in 2014 at the Joseph Ravoahangy
Andrianavalona University Hospital [5]. In our study, the prevalence
of VTE was 6/10,000 women per year. This low incidence would
probably come from an underestimation of the disease, the mode
of recruitment, which is only concerned with symptomatic venous
thromboembolic diseases, but especially because the CHUGOB is
attended only by women with gynecological pathologies and or
obstetric. Indeed, according to the literature, asymptomatic forms
of MTEV constitute 15.8% to 50% of cases [10,11]. The mean age
of the patients was 37.74 years with a standard deviation of 11.86
and the extreme ages were 18 and 63 years respectively. Fifty-six
percent of our patients were in the 20 to 30 age group. This could
be explained by the fact that this age group corresponds to the
period of maximum genital activity is therefore to the association of
thromboembolic events: pregnancy, the postpartum period and the
use of oral contraception. In this age group, the incidence of VTE is
estimated to be less than 0.2 / 1000 women per year among those
under 20; 0.3 / 1000 women per year aged 20 to 30; 0.45 / 1,000
women per year aged 30 to 45 years [12]. According to Naess IA
et al, the incidence of MTEV is higher in women than men before
age 50 [13]. In developed countries, patients with the disease had a
higher average age at age 65 [14,15]. Metrorrhagia was in first place
with 10 cases, or 37%, half of which was related to gynecological
cancers. Venous thromboembolism in many studies is secondary
to active cancers. According to Esmon CT, cancer increases the
thromboembolic risk by 6 to 10 times [16]. The highest risk
cancers of VTE are those of the pancreas, stomach, genitourinary
tract, lung, colon and breast [16]. In Algeria, one-third of cancer
patients developed thromboses [8]. In Uganda, Andrew L et al. have
found that, apart from surgery, cancer is the factor most associated
with thrombosis [17]. In Madagascar the frequency of venous
thromboembolism in patients with cancer is not known. Our study
therefore participates in the constitution of a database in this sense.
In Raveloson’s study, lower limb pain is the most observed pattern.
This pattern is followed by unilateral edema of MIs in the case of
TVPMI, dyspnea and chest pain for pulmonary embolism [3]. Thus,
VTE is the reason for hospitalization in their studies. In our study,
77.78% of our patients are referred by other practitioners and /
or care institutions in the Gob CHU for gynecological and obstetric
reasons. Either they are referred for metrorrhagia related to
cancer, or for pelvic pain related to work. Only two cases, 7.41%,
were admitted for suspicion of thrombophlebitis associated with
pregnancy and three cases for postpartum dyspnea. Thus, in our
study, VTE is a pathology strongly related to hospitalization. As
for risk factors, according to the literature, pregnancy in itself
represents a period when the thrombotic risk is increased by
physiological disturbances: tendency to hypercoagulability linked
on the one hand to mechanical factors and on the other hand
partly to biological modifications [12]. The risk analysis of MTEV
made by Gris JC et al. Showed a low rate during the first trimester
of pregnancy, a doubled risk in the second trimester and a sixfold
increase in the risk during the third trimester [18]. In our study, the
risk factor represented by pregnancy is found in 18.51% of cases,
of which 40% were in the first and third trimester and 20% in the
second trimester of pregnancy. This discrepancy can be explained
by the low number of samples. In a Korean PAPE study (Pregnancy-
Associated PulmonaryEmbolism), all cases of pulmonary embolism
occurred in the postpartum period after caesarean section [12].
In Sudan, the risk of thrombosis during the postpartum period
is 94% [17]. In our study, the postpartum period was found in
first place with a rate of 40.74% of which 63.63% after caesarean
section and 36.37% after vaginal delivery. Estrogen / progestin
contraception is one of the risk factors with high thrombogenic
potential [19]. It increases the risk of venous thrombosis by five
[20,21]. In our study, oral contraception is one of the risk factors for
VTE because it is found in 11.11% of cases. This result is close to that
found by Raveloson et al. [3]. Patients with heart failure are older
and may be immobilized for a period of time [22]. According to the
literature, the discovery of heart failure increases the risk of VTE by
up to 15 to 30% [23]. According to a study of MTEV and pregnancy
performed in Benin, the incidence of heart failure as a risk factor
is 3.9% [1]. In our study, heart failure is found in 15% of cases as
the literature describes it. In our study, one case in twenty-seven
(3.7%) had a personal history of VTE whose seniority compared
to the first incident was not reported in medical observation. This
rate is much lower than the results found by Kingue et al. and by
Nourelhoud et al, which are respectively 16.7% and 12% [19,24].
This difference can only be explained by the underestimation
of the illness or by her lack of knowledge of her illness. VTE is a
multifactorial pathology involving constitutional, acquired and
environmental risk factors [25,26]. According to the literature,
almost 80% of hospitalized patients have at least one risk factor
for VTE, 50% have at least two risk factors [25]. This result is close
to ours, which is 62.96%. Clinically, Raveloson et al. proposed that
the Wells score with medium or high clinical probability, with or
without a positive D-Dimer, is sufficient to establish the diagnosis
of VTE [3]. In our study 59, 26% of our patients have high clinical
probability scores; 37.03% intermediate and 3.7% weak. In our
study, MTEV is located mainly in the lower limbs in 19 patients
(70.37%), with slightly higher involvement of the lower left limb
in 10 cases or 37.04%. The preferred location of MTEV is on the
lower left limb. This predilection is due to the compression of the
left primary iliac vein by the right primary iliac artery and the
gravid uterus. Paraclinically, in our study, 89% of the patients could
not do the dosage of D-Dimers because of insufficient financial
means, the impossibility of carrying out this test within the same
establishment. However, this examination has a high negative
predictive value that can quickly eliminate ambiguous forms.
Ultrasound is a non-invasive examination that is widely available
within CHUGOB where our study was conducted. Unfortunately,
venous ultrasound is not available to all and the technicians who
work there do not practice this examination. Thus, only 80% of our
patients experienced it by performing it outside the establishment.
CT angiography is the gold standard for the diagnosis of PE because
its sensitivity and specificity are high, ranging from 64 to 100%
and 89 to 100%, respectively [22]. However, this examination is
financially inaccessible to the majority of patients from which no
patient has benefited. As for the treatment, for the prevention, in our
study the preventive means are indicated for the patients
who had undergone a cesarean operation. These means are
mainly the early and routine administration of enoxaparin 0.4 ml
subcutaneously at the sixth hour postoperatively and for 48 hours
[27]. Note that the elevation of the members and the BAT have not
been used as a means of prevention because the cost of the latter
is too high and therefore not within the reach of patients admitted
to CHUGOB. But despite this preventive treatment, of the 10 cases,
37%; 8 cases developed DVT and 2 cases fatal pulmonary embolism.
The explanation is that the prevention modalities were completely
unsatisfactory and / or unsuitable. Indeed, for lack of diagnosis (lack
of imagery and biology) the curative treatment for the 2 deceased
cases could not be started. And as for the curative treatment of
MTEV, it is mainly based on anticoagulants. The recommendation
consists of two stages: heparin treatment and early releasing with
vitamin K antagonists (AVK). Heparin treatment will be continued
for one week to 10 days because of the risk of heparin-induced
thrombocytopenia and until an INR is obtained in the therapeutic
zone (between 2 and 3) in two consecutive samples at 48 hours.
intervals [27,28].
Other treatments include treatment of the contributing
factors, symptomatic treatment (analgesic, nonsteroidal antiinflammatory
drug, oxygen therapy), strict bed rest at the
beginning of anticoagulant treatment and education of patients
and their families [3]. During our study, 81% of the patients were
able to benefit from enoxaparin but only 52% of them were relayed
by AVK, considering the state of pregnancy which against the
AVK, some of our patients died after that the diagnosis be made
and that the heparinotherapy is established and lack of financial
means for the purchase of medication and the achievement of
monitoring report. This same problem is often encountered
in other developing countries of Africa [29,24]. Regarding the
evolution, according to the literature, the mortality and morbidity
of venous thromboembolism are directly correlated with the
speed of its diagnosis and its therapeutic management. Mortality
drops significantly if diagnosis and treatment begin promptly
[29]. A study by Julien Lefèvre on the epidemiology of maternal
mortality in hospitals found a mortality rate of 11.11% for all
cases, a maternal mortality rate of 2.3 per 100,000 births. In the
United States, one third of deaths from pulmonary embolism occur
within one hour of the first symptoms. The mortality rate among
hospitalized patients during the first episode is 12%; the diagnosis
of pulmonary embolism is not suspected in more than 70% of
patients who died [30]. In our study, the mortality rate represents
10 out of 27 cases (37%). They are all related to PE. In 8 out of
10 cases (30%), death occurred in the postpartum period and in
2 cases by complicating a gynecological cancer. There is a great
discrepancy between the results announced by the literature and
ours. The possible explanation for this discrepancy may be our
ability to label the diagnosis of death as pulmonary embolism
without any radiological or biological support or post-mortem
examination being performed. These same problems are found by
other authors in developing countries [3,9].
Conclusion
Thromboembolic disease is a unique pathology involving the
cardiologist, resuscitator, gynecologist, obstetrician, oncologist,
neurologist, ... The female predominance of MTEV in Malagasy
studies gave the inspiration for this study. So, his goal was to
determine the characteristics of this disease at the Gob Hospital.
During a four-year period (from January 1, 2011 to December 31,
2014), 42,443 patients had been hospitalized at the University
Hospital Center of Gynecology and Obstetrics of Befelatanana.
Twenty-seven of them were identified as having a VTE or 0.06%
and in 15 cases (55%) it was TVPMI, 8 cases (or 30%) PE and 4
cases (either 15%) of TVPMI complicated with EP. Age greater than
40 years, menopause, prolonged immobilization, gynecological
cancer, pregnancy were the most frequently identified risk factors.
The knowledge of these factors added to the clinical probability
score is a major aid in the diagnosis and management of patients.
The practice of preventive measures in this study only concerns
post-caesarized patients. However, ten out of twenty-seven cases
died by MTEV including eight cases in postpartum and two cases
following cancer. These results should contribute to improving
the management of the disease through a systematic assessment
of risk factors, a well-conducted clinical approach, a provision
of diagnostic and surveillance equipment, the establishment of
prevention in patients at risk and training of health personnel.
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