Case ReportPersonal Hx

• Mrs S. A

• 26 yrs .

• Married for 10 yrs.

• Primigravida

• IVF Twin Pregnancy - 34 weeks of gestation.

• Presented to Obstetric Emergancy Department on 07.01.2013.

Chief complain:• Left leg swelling and pain. Hx of present illness :

• One day prior to admission Pt complained of left leg heaviness followed by swelling and pain.

Obstetric Hx• PG pregnant at 34 weeks twin pregnancy after

successful IVF trial in Egypt .• She had H/O primary infertility for 10 years due

to male factor.• She had also failed of two IVF trial, one in Gaza

and the other one in Egypt.

Gynecologic Hx: Normal menarche & menses.

Past Hx : No DM, No HTN and No previous history of DVT.

Drug Hx: Tonics, Omega -3, Nefedipine as a tocolytic started at 32 Wk and Dexametasone at 32 Wk.

Family Hx : Father is hypertensive . No familial history of DVT

Booking

• Up to 14 Wk Egypt

• After 16 Wks Primary Heath care + Private Clinic

on AdmissionPHYSICAL EXAMINATIONLooks well, conscious , no dyspnea, no cyanosis and no chest pain.

Vital Signs:• T= 37.1oC BP= 110/70 mmHg• RR= 16 bpm HR=88 bpm R bil

on Admission

• Chest: No crepitation

• Abdomen: extended with gravid uterus .FL± FT• Cardiac: RRR, no murmur appreciated, no JVD.

• Lower Limb: Left culf mascle swelling, redness and tenderness.

Right leg Left leg

Above the knee 41cm 42cm

Bellow the knee 53cm 58cm

In summary,,,

• Mrs S. A. is 26 yrs , PG, Pregnant at 34 wk IVF twins with left calf muscle swelling, pain and tenderness .

The Impression

• Left leg DVT

PROGRESS IN HOSPITAL

• Admission

• IV Line

• Lab investigation

• Fetal wellbeing ( USS – CTG)

• Urgent Doppler USS

INVESTIGATIONS

• BG:BG: A+ve A+ve• CBC :CBC :

• Chemistry :Chemistry :

WBC HB PLT

10.300 11.1 210,000

AST ALT RBS urea Uric acid creatinin

23 19 95 14 3.1 0.6

Doppler USS

• Left leg popliteal DVT.

Hospital course• CBC , CUA, KFT, LFT, Coagulation

profile

• Heparin SC protocol (Loading: 20000IU + Maintenance: 15000 IU BID)

• B P chart

• Daily PTT

Clinical Progress

• After 2 days very good clinical improvement.

• PTT level = adequate anticoagulation

• Same dose Heparin continued (15000 BID-SC)

Initial7/1/13

After 2days9/7/13

After 1 week14/1/13

Serial PTT 32 48 52

Clinical Progress

• On 20/ 01//2013 while the patient was at 35w+6 Wk of gestation, she developed generalized severe left leg swelling and pain.

Urgent Re- Doppler USS Massive popliteal and femoral VT

Problem

• 1. Inspite of adequte of anticoagulation therapy we are faced with a a case of recurrent massive left leg DVT.

• 2. The patient is 36 wk, IVF twin pregnancy, a waiting for cesarean section delivery in presence of massive left popliteo-femoral DVT.

Quastions

• Is it safe to do pelvic surgery (CS) in presence of acute massive DVT?

• What is the hazards?

VTE and Pulmonary embolism in pregnancy• Pregnant women are at an increased risk

for venous thromboembolic disease (VTE) • 1 in 1000 pregnancies• The risk of DVT and subsequent pulmonary

embolism in pregnant women is six times higher than in non-pregnant.

• Cesarean delivery > vaginal delivery• Daily risk of PE and DVT highest following delivery

than antepartum.• 43-60% of PE occur 4-6 weeks after delivery• PE is the the most common cause of direct

maternal death. • 2/100 000 pregnancies

Why is the risk greater in pregnancy?

Independent risk factors of a higher VTE risk in pregnancy?• Bed rest• Multiparity • Advanced maternal age (>35 y.o.)• Overweight• Personal or family history of VTE• Preeclampsia

Quastions

• Is it safe to do pelvic surgery (CS) in presence of acute massive DVT?

• What is the hazards?

Quastions

• Is it safe to do pelvic surgery (CS) in presence of acute massive DVT?

NO

Because of increased risk of propagation of a distal thrombus toward the pulmonary vessels (Pulmonary Embolism).

• How to reduce this risk?

How To reduce maternal death in pregnancy due to DVT and pulmonary embolism?

• Anticoagulation treatment should be started as soon as a diagnosis is made.

• Placement of an inferior vena cava filter is a feasible and effective choice when :

- recurrent thromboembolism occurs despite adequate anticoagulation or

- when anticoagulation is contraindicated for therapeutic or prophylactic indications.

Decision

• To shift heparin treatment from SC to IV infusion ( 1200IU per hour)

• To place Inferior Vena Cava Filter

• To do elective CS

Why IVC Filter in our patient?• The postpartum period is conceded to be the highest-

risk period for venous thromboembolism and pulmonary embolism in pregnant patient.

• Our patient was considered to be at high risk of intrapartum and postpartum pulmonary embolism.

• The risk of pulmonary embolism increases due to the discontinuation of anticoagulation and the hemodynamic changes accompanying the rapid decompression of the venous system after delivery

IVC implantatonEGH Cath Lab Dep. - 22/01/2013

Procedure: Cavogram was done via right femoral vein ( IVC – 25cm) then long sheet was inserted and IVC filter ( cook celect vena cava filter, E2664200, ref: IGTCFS-65-2-UNI-CELECT) was implanted in the IVC below the rena veins without complications.

Team : Dr. Mohammed Habib , Dr Waeil Hijazi, Dr. Hassan Zammmar, Dr. Eyad Saafeen.

IVC implantatonEGH Cath Lab Dep. - 2/1/13

Facts about IVC Filters

• First reported by Greenfield in 1967. • IVC filter placement in pregnancy was first

presented in 1973• The procedure has been justified to reduce

the risk of significant recurrent pulmonary embolism to 1% to 3% in the nonpregnant population.

• Optional Filters (temporary - retrievable or permanent)

Indications of IVC Filter in non-pregnant patient

Confirmed DVT or pulmonary embolism with a contraindication to or complication with heparin therapy

Recurrent pulmonary embolism despite adequate anticoagulation.

Other relative indications include a free-floatingthrombus documented by means of Doppler

ultrasound imaging and the presence of extensive iliac thrombosis that may result in pulmonary embolism

Indications of IVC Filter in pregnant patient

• In patients with DVT early in the first or second trimester of pregnancy are in accord with those in non-pregnant patients.

• For prophylactic prevention of intrapartum and postpartum pulmonary embolism in term pregnant patients with DVT of the lower extremities

A- Indications

I- Absolute indications (proven VTE)• 1. Recurrent venous thrombo embolism "VTE"

(Acute• or chronic) despite adequate anticoagulation. 2.• Contraindications to anticoagulation. 3.• Complications of anticoagulation. 4. Inability to• achieve/ maintain therapeutic anticoagulation.

A- IndicationsII- Relative indications (proven VTE):• 1. Ilio- caval DVT. • 2. Large free- floating proximal DVT. • 3.Difficulty establishing therapeutic anticoagulation. • 4. Massive pulmonary embolism treated with thrombolysis/

thrombectomy.• 5.Chronic PE treated with thromboendartrectomy.• 6. Thrombolysis for iliocaval DVT. • 7.VTE with limited cardiopulmonary reserve.• 8.Recurrent PE with filter in place. • 9.Poor compliance with anticoagulant medications. • 10.High risk complication of anticoagulation (e.g., ataxia, frequent falls).

A- Indications

III- Prophylactic indications (NO VTE, Primary prophylaxis not feasible*)

• 1. Trauma patient with high risk of VTE. • 2. Surgical procedure in a patient at high risk of VTE. • 3. Medical condition with high risk of VTE.

B- Contraindications to filter placement

• 1. No access route to the vena cava. • 2. No location available in vena cave for placement of filter

* Primary prophylaxis not feasible as a result of high bleeding risk, inability to monitor the patient for VTE.

Caesarean Section• Heparin infusion stopped 5 hour before surgery• Elective CS performed on 23/1/13• Uneventful procedure• Outcome healthy 2 female baby, WT: 3 - 2.7kg• Post CS after 8 hour Clexan 80 mg BID started• Uneventful postoperative period• On 26/1/13 warfarin 5mg Tb OD started, and after

3 days when INR raised > 2 Clexan treatment discontinued.

• On 29/3/13 patient discharged on Warfarin 5mg Tb OD treatment.

IVC filters: benefits and risks Decousus, NEJM 2005

400 patients with proximal DVT, 50% with PE

Filter No filter p

PE at day 12 1% 5% 0.03 PE at 2 years 3% 6% NS

DVT at 2 years 21% 12% 0.02 Death 22% 21% NS Major bleed 9% 12% NS

Retrievable IVC filters

• FDA approved• Ideal for young patients with reversible PE risk factors• Left in, they become permanent

– Current duration < 2 weeks

Thrombophilia gene mutation

Prothrombin Factor XIII ACE

Normal Normal Heterozygous

Antithrombin III Factor V Leiden MTHFR PAI-1 gene

Normal Normal Normal Heterozygous

Conclusion• Pregnancy is a hypercoagulable status, associated with

increased risk of DVT and life threatening PE especially in postpartum period.

• Time has come for a second thought about the role of bed rest and thromboprophylaxis in IVF pregnant patients.

• IVC filter placement should be consider for patients with DVT in term pregnancy who are at particularly high risk of intrapartum and postpartum pulmonary embolism.

• IVC filters are an effective and safe method in the prophylaxis and therapy of VTE in pregnancy, and this use right before labor has been justified by several studies.

• Retrievable filters might reduce long-term complications.

Thank You