///2009 Abstract Details
2009 Abstract Details2019-08-03T15:55:31-06:00

Upper Extremity Venous Thrombus after Manual Replacement of Uterine Inversion under General Anesthesia

Abstract Number: 245
Abstract Type: Case Report/Case Series

Julie P Ma B.S, M.D.1 ; H. Jane Huffnagle D.O.2; Suzanne Huffnagle D.O.3; Rehana Jan M.D.4

Introduction: Although pregnancy is a hypercoagulable state, certain circumstances can further predispose to unintentional venous thromboembolism (VTE).

Case Presentation: A 52", 73 kg, 40 y/o, G3 P1 female on methyldopa for HTN, presented in labor. She received an epidural and had a SVD. Upon extraction of the placenta, a partial uterine inversion occurred. Manual replacement under GA was needed. An 18 g IV was present in the LUE and BP was 50/30. The left arm BP cuff was repeatedly inflated since readings were difficult to obtain. After 30 mL sodium bicitrate and an infusion of PRBCs, standard monitors were applied and a RSI was performed with etomidate and succinylcholine. Anesthesia was maintained with 1% sevoflurane, 50% N2O, and O2. An IV was started in the R hand and a 2nd unit of PRBCs was given. Hemoglobin was 8.9 after infusing of the 2nd unit (preop Hgb 11.1). Nitroglycerin 20 mcg IV was given to relax the uterus and it was manually replaced. The patient received 40 units of oxytocin/1L NSS, 800 mcg of misoprostol PR, and 250 mcg of prostaglandin F2 IM. EBL was 1500 mL. She was extubated and transported to the PACU. On POD #1, she had LUE swelling extending from the elbow to the fingers with decreased ability to flex and extend her fingers. Her LUE 18 g IV had been removed 19 hours prior without notable swelling. LUE ultrasound revealed acute superficial venous thrombus involving the left cephalic vein from the antecubital fossa to the forearm.

Discussion: Every pregnant patient is at risk for VTE; relative risk is 4.3 in pregnant or postpartum women compared with nonpregnant women.(1) Particular pregnant women are at even higher risk: age > 35, obesity (BMI > than 30 kg/m2), grand multiparity, personal/family history of VTE, thrombophilias (e.g. factor V Leiden, prothrombin gene mutations, protein C deficiency, antiphosplipid antibody syndrome), immobility  4 days, hyperemesis, dehydration, medical problems (e.g. severe infection, sickle cell disease, CHF, nephrotic syndrome) preeclampsia, severe varicose veins, recent surgery, recent trauma, blood transfusion, cesarean delivery, and postpartum mothers.(2) Pregnancy produces all the components of Virchows triad (hypercoagulation, venous stasis and vascular injury) which contribute to thrombosis. Increases in coagulation factors lead to a hypercoagulable state. Venous stasis occurs as capacitance vessels dilate while venous return is diminished by the gravid uterus.(3) Vascular injury occurs during both vaginal and cesarean delivery from tissue trauma. Multiple risk factors as well as increased venous stasis from frequent BP cuff inflation may have led to this LUE thrombosis.

References: 1. Heit JA, Kobbervig CE, James AH, et al. Ann Intern Med. 2005; 143(10):697-706., 2. Dresang LT, Fontaine P, Leeman L, et al. American Family Physician 2008; 77(12): 1709-1716., 3. Nelson SM, Greer IA. Obstet and Gynecol Clin of North America 2006; 33: 413-427.

SOAP 2009