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Obstetric and Anesthetic Management of a Parturient with Extensive Lower Extremity DVT
Abstract Number: S 65
Abstract Type: Case Report/Case Series
This case report describes the obstetric and anesthetic management in the peripartum period of a 31 year-old G1P0 parturient on anticoagulation therapy for an extensive deep venous thrombus (DVT) in the left lower extremity. Her past medical history was significant for Factor V Leiden deficiency and asthma. At 33 weeks gestation, she developed extensive venous thrombus involving the left proximal superficial femoral, the great saphenous, the common femoral and the external iliac veins. Therapeutic anticoagulation was started with enoxaparin and switched to heparin infusion after she was admitted to the labor and delivery suite for induction of labor at 39 weeks gestation. When she progressed into active labor, the heparin infusion was discontinued in anticipation of labor epidural placement. A labor epidural catheter was placed uneventfully with one attempt four hours after stopping the heparin infusion and upon obtaining a normal PTT. Approximately twelve hours after the epidural was placed, she developed a non-reassuring fetal heart tracing and underwent an uneventful stat cesarean section with delivery of a healthy infant. She was administered heparin subcutaneously two hours after surgery and epidural catheter removal and restarted on therapeutic enoxaparin twelve hours after surgery. The patient was discharged home on postoperative day four and underwent successful percutaneous thromboplasty four months after delivery due to persistent extensive lower extremity thrombus and edema despite therapeutic anticoagulation.
The estimated incidence of deep venous thrombosis is 5-12 per 10,000 pregnancies in antepartum and 3-7 per 10,000 pregnancies during postpartum period (1). When compared with non-pregnant controls, the daily risk for parturient to develop DVT is increased 10 to 30 fold (2). Combined with pulmonary embolism, it is a leading cause of maternal death in the developed world (3). However, current management guidelines are largely extrapolated from data obtained in non-pregnant patients due to limited data available from the pregnant patient population. Our case report describes the peripartum management of extensive lower extremity DVT and reviews the etiology, risk factors, current management guidelines and considerations for surgical (IVC filter placement) versus medical (anti-coagulation only) approaches.
1. Simpson, EL, Lawrence RA, Nightingale, AL, Farmer RD. Venous thromboembolism in pregnancy and the puerperium: incidence and additional risk factors from a London perinatal database. BJOG. 2001;108:56-60
2. Heit JA, Kobbervig CE, James AH, et al. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. Ann Intern Med. 2005;143:697-706
3. Marc Rodger. Evidence base for the management of venous thromboembolism in pregnancy. Hematology.2010;1:173-180.