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Forum Name: Ischemic Heart Disease

Question: 3 Blood Clots in Upper Extremeties


 Branson Evans - Wed Jan 19, 2005 2:25 am

My sister had to have a PICC line inserted into her right arm due to being pregnant and having rather extreme Hyperemesis. While the nurse was inserting the line my sister heard "popping" noises and felt a little discomfort. After a few days of increasingly horrendous pain the PICC was removed and 2 DVT's were found; one in her internal jugular and another in her subclavian vein.
They put her on 105mg of Lovenox per day right away. The Hyperemisis was still bad so they inserted a mid-line in her left arm. Well, she formed a small superficial clot (about 1" along the vein wall) in the left cephalic vein where the mid-line had been placed, so they doubled her Lovenox to 2 doses of 75mg each per day and removed the mid-line. Four days after starting the extra amounts of Lovenox, the clot in the cephalic is shown by ultrasound to be about 6-7" long.
She has been tested for all of the major clotting factors and has come back negative on each of them. The doctors say the jugular and subclavian clots are now occlusive and "should not" break free and cause a pulmonary embolism. Unfortunately, after 5 days in the hospital they have decided to send her home and put her on bedrest with bathroom privileges only for the next 10 days. Even though her oxygen levels have dipped to 89% after being at 96-98% for all the other days she was in the hospital they still decided to send her home. I guess my questions are:
1. How worried need we be?
2. Seeing how the jugular and subclavian clots are occlusive, what are the chances of them breaking free?
3. After my sister has her baby will she be able to go on Urokinase or streptokinase to help dissolve the clots, or will it be too late to really make a difference and her body will have to naturally break them down over time?
4. What if the clots don't dissolve over time, will my sister have to "take it easy" for the rest of her life?

I am sorry for so many questions, I don't need a long answer. My family and I have been on quite the emotional rollercoaster over the last week or so and a few extra answers would really be helpful and comforting. Thank you!
 Theresa Jones, RN - Wed Jan 19, 2005 1:07 pm

User avatar Hi Branson,
I can certainly understand your concern and emotional roller coaster. Generally speaking as far as a time frame these drugs streptokinase and urokinase are used within a few hours of a heart attack or stroke. They are used without any particular time frame for dissolving blood clots. They may be used during pregnancy but not generally during the first 5 months due to the increased risk of miscarriage. Now my concerns and questions are, did they put her on any sort of blood thinner upon discharge? How did they rule out a pulmonary embolism? Oxygen saturation of 89% compared to the upper 90's concerns me as well. Is she short of breath, having any sort of chest pain? My other concern is when you stated occlusive, did they tell you that the blood clots were blocking blood flow in these areas? Please keep in mind that yes, blood clots can be dissolved and no it is unlikely that she would be on bed rest or have to "take it easy" for the rest of her life. You didn't state how far along in her pregnancy she was and has she ever been given any vitamin b12 shots to help reduce the hyperemesis because in some women this has been effective. I am also forwarding this to the doctors on the forum for a more extensive opinion.
Sincerely,
Rntdj
 Branson Evans - Wed Jan 19, 2005 4:24 pm

Thank you for your prompt reply! My sister is still on the Lovenox of 75mg twice a day (9am and 9pm). She is 12 weeks pregnant on Sunday. She has B12 pills but they did not help her enough. The pulmonary embolism was ruled out by X-ray and a normal EKG. I have told her to watch for any shortness of breath and all the things that may resemble a PE and she has no pain in her chest..just a little tightness that the doctors say is probably due to the lovenox and laying down all day. The occlusive clots are currently not blocking the vein....they say that it is letting as much blood through as normal, but it is still allowing enough through that it isn't a major concern right now. Thank you so much for your help!
 Dr. Yasser Mokhtar - Thu Jan 20, 2005 1:50 am

User avatar Dear Branson,

As a measure to protect the mother against bleeding during pregnancy and labor, the blood becomes more coagulable. However, this does not mean that pregnant females should get dvts as part of a normal pregnancy or even post-partum. At this age, dvts usually ignite a battery of blood work to make sure that the patient does not have an hypercoagulable condition that requires treatment for life.

With hyperemesis and the resulting dehydration that ensues, the blood becomes even more prone to clotting.

Once in place, and this is easy to imagine, the picc line made the lumen of the vein smaller and the blood flow through it slower.

And in addition to the trauma of inserting an iv, the three major risk factors (increase in coagulability of the blood, trauma to the vessel wall and stasis of the blood) come playing together to cause thrombosis of the blood in the vein.

Pulmonary thrombosis can happen even without a dvt complicated by a part of the clot separated and going to the lungs.

There is an increased risk of pulmonary embolism from upper extremity dvt but much less than lower extremity dvt.

After ten days, the patient can resume his/her normal life because the clot becomes firmly adherent to the wall and the chances of separation become less (but are still there).

Pulmonary embolism is not easy to diagnose during pregnancy because of the high radiation exposure associated with various diagnostic procedures and the risk of miscarriage and/or fetal abnormalities. But most probably it is not really important to confirm the diagnosis of pulmonary embolism because the treatment is going to be the same as dvt which is anticoagulation.

In cases of pregnant females, saturations have to be kept a little bit higher than high 80's, they have to be in the mid 90's, as pregnant females have less reserve than the non-pregnant women.

Thrombolytic therapy (stroptokinase, urokinase) have certain indications in cases of venous thrombosis. They can be used in cases of upper extremity dvt as well.

Treatment of dvt has to be at least 3 months in patients with low risk for recurrence of dvt, 6 months for patients with intermediate risk and indefintely in cases of patients with high risk.

In cases of pregnancy, the patient is treated till the end of pregnancy with heparin and then patient is switched to warfarin.

Heparin (lovenox is a low molecular weight heparin) has a major side effects in cases it is given long term which is osteoporosis, so your sister has to take a satsifactory amount of calcium and vitamin d.

Thank you very much for using our website http://doctorslounge.com and i hope that this information helped.

Yasser Mokhtar, M.D.
 Branson Evans - Thu Jan 20, 2005 3:10 am

Thank you so much! You have made me feel much more comfortable with this whole ordeal....although I still want my sister on bed rest for longer than 10 days, just because it will make me feel better! ;) Honestly, thank you and your site for the prompt replies!

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