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Two Ends of The Spectrum: Hypercoagulability & Bleeding Risk. A case of Pulmonary Embolism & PostPartum Hemorrhage
Abstract Number: F2C-5
Abstract Type: Case Report/Case Series
Background: The risk of VTE is 3-7/10000 pregnancies in the puerperium. Risk of post partum hemorrhage (PPH) after elective C section is 4.84%.
Case Presentation: 34 yo female G6 P3023 @ 39 weeks with history of hypertension scheduled for repeat C section with BTL due to 3 prior C sections. 3rd C section significant for intraabdominal adhesions. Surgical anesthesia obtained with combined spinal epidural (CSE). Intraoperative course was complicated by adhesive disease. Blood loss 830 mL.
Postoperatively, she had PV bleeding and received carboprost. She later complained of right abdominal pain and SOB. On assessment, was tachycardic with mild hypotension, associated with intermittent desaturations requiring supplemental oxygen. Initial work up led to CT chest & abdomen which showed bilateral subsegmental pulmonary emboli (PE) and abdominal hematoma without active extravasation. She was admitted to ICU for serial abdominal examinations & CBCs. IV heparin was started but was stopped early in the course as concerns for re-exploratory laparotomy became increased.
A fall in the postoperative Hgb from 11.3 to 8.8 after 4 hours in the setting of increased abdominal pain, distention and oozing from the incision site led to the decision for exploratory laparotomy while transfusing 2 units of PRBC due. Labs were negative for DIC.
RSI was done for exploratory laparotomy. Maintenance was done with sevoflurane and remifentanil infusion due to Intrathecal morphine given at time of CSE about 10 hours prior. An arterial line was placed. Intraoperatively, 1800 ml of hemoperitoneum was found & the bleeding source was the site of tubal ligation. She was extubated and transferred to the PACU. She was discharged from the ICU on POD1 and discharged home on POD 5.
Discussion: When corrected for the duration, the risk of VTE in the puerperium is 7 times that in the antepartum period. Studies have varied in the reported incidence of VTE before during or after pregnancy but during pregnancy, the incidence is about the same across all trimesters.
Pregnancy entails all elements of Virchow’s Triad:
Venous Stasis: Venodilation and mechanical compression of the gravid uterus.
Hypercoagulabiltity: Overall increase in clotting factors, decreased Protein S & increased resistance to protein C.
Endothelial injury – Usually at the time of delivery whether vaginal or Cesarean.
Additional risk factors for VTE in pregnancy include obesity (BMI> 25 at the 1st antenatal visit), race (African Americans have the highest incidence) & smoking. Other factors are inconsistently identified in some studies: age, parity & cesarean delivery.
Magann, Everett F., et al. “Postpartum Hemorrhage After Cesarean Delivery: An Analysis of Risk Factors.” Southern Medical Journal, vol. 98, no. 7, 2005, pp. 681–685., doi:10.1097/01.smj.0000163309.53317.b8. Miller, Margaret A., et al. “Peripartum Pulmonary Embolism.” Clinics in Chest Medicine, vol. 32, no. 1, 2011,