Venous thromboembolism (VTE) is a major cause of pregnancy-associated morbidity and mortality; most VTE are deep venous thromboses (DVT).1 This case report presents a unique case of intrapartum DVT. The patient was a 33-year-old gravida 1 at 39+0 weeks of pregnancy with notable past medical history of a pre-gravid body mass index (calculated as weight in kilograms divided by the square of height in meters) of 28 and gestational diabetes. She denied personal or family history of thrombosis. She received an epidural early in her labor induction process (Figure 1). About 22 h into her induction, the patient developed new bilateral lower extremity edema, worse on the right. Imaging showed non-occlusive thrombi in both the right profunda femoris and the left popliteal veins. Given her intermittent category II tracing remote from delivery and acute DVT, the decision was made to proceed with a cesarean delivery. Therapeutic unfractionated heparin was initiated 1 h after the end of the cesarean and removal of her epidural catheter. On hospital day 3, the patient was found to have large pericolic and bilateral rectus sheath hematomas but no evidence of active extravasation. Her heparin was paused. She later underwent prophylactic gel-foam embolization of her bilateral uterine arteries and placement of an infrarenal Denali inferior vena cava (IVC) filter. She ultimately resumed anticoagulation with Lovenox 1 mg/kg twice daily 5 days following her initial cesarean. On hospital day 9 she was discharged home with the IVC filter still in place and a plan for at least 3–6 months of therapeutic anticoagulation. She has been doing well at follow-up appointment. This novel case report highlights the delicate balance between anticoagulation and hemorrhage risk in the immediate postpartum period. It was imperative to treat the patient's DVT as soon as possible because the risk her clot progressing into a potentially fatal pulmonary embolism was unknown. Treatment for DVT is generally with pharmacotherapy, placement of an IVC filter, or mechanical thrombolysis.2 Heparin is preferred in the acute setting because of the presence of a reversal agent and the availability of data.3, 4 Consideration was given to initiating prophylactic rather than therapeutic anticoagulation; however, this was thought to be suboptimal given the superiority of therapeutic dosing in preventing clot progression.4 Due to the recommendation to begin therapeutic anticoagulation as soon as possible, the inability to do so with an epidural catheter in place, and the intermittent category II tracing with slow progression and uncertain length of time until delivery, the decision was made to proceed with a cesarean to expedite delivery and the initiation of anticoagulation. Unfortunately, the patient developed bleeding complications from the use of anticoagulation in the immediate postoperative period. Even in cohorts who initiate therapeutic heparin 4–6 h postoperatively, almost 10% will have bleeding complications.5 Compounding this, how effectively heparin administration maintains a therapeutic range is influenced by many clinical factors and can be challenging.3, 4 This occurred here and the patient had variable activated partial thromboplastin time values despite a goal anti-factor Xa level between 0.3 and 0.7 U/mL. Hemorrhage likely related to expeditious initiation of anticoagulation eventually delayed her pharmacotherapy for several days. A handful of case reports exist of individuals who developed an acute pulmonary embolism during delivery.6, 7 These reports stress the importance of timely application of intensive therapy; however, these women also developed bleeding complications. This case report highlights the need for further research on alternatives to pharmacologic anticoagulation in the peripartum setting. Some of our patient's morbidity may have been avoided by placement of the IVC filter at the time of diagnosis as opposed to expediting delivery to permit initiation of therapeutic anticoagulation. At the time, however, she was not felt to have an absolute contraindication to pharmacotherapy and hence IVC filter placement was not pursued. In hindsight, this could have been considered earlier. This case report underscores the importance of considering hemorrhage risk in initiation of anticoagulation in the peripartum setting. It brings attention to a gap in management guidelines for anticoagulation and VTE in pregnancy. Current guidelines on the management of venous thromboembolic disease in pregnancy discuss recommendations for anticoagulation before labor, but there are scant recommendations on intrapartum DVT.1, 8 Clinical learning points also include that, though rare, it is possible to develop a DVT intrapartum, and patients should be evaluated and treated promptly. It is important to work with a multidisciplinary team to develop the best course of action for these patients. This study was deemed exempt by the Institutional Review Board Health Sciences Research of the University of Virginia. As part of the exemption criteria, the patient gave verbal permission for the development of this case report. All authors contributed equally to information collection, and to the writing and editing of this case report. The authors have no conflicts of interest. Data sharing is not applicable to this article as no new data were created or analyzed in this study.
Arimoro et al. (Tue,) studied this question.