Fetal Demise due to Uterine Trauma With Massive Intraperitoneal Hemorrhage Associated With Chronic Perforation of the Inferior Vena Cava by an Infrarenal Filter: A Case Report With Call for Definitive Consensus Regarding Filter Positioning in Nonpregnant Women of Childbearing Age

Abstract

Suprarenal placement of inferior vena cava (IVC) filters in women of childbearing age has been recommended largely based upon theoretic concerns for safety of the mother and fetus. However, cases of filter-related maternal and fetal injuries have not been previously reported. Instructions for use of commercially available permanent and retrievable IVC filters do not make distinctions based on age or sex. Although most IVC filters implanted in current practice are potentially retrievable, less than 50% are ever removed. We present the first report of serious maternal injury and fetal death resulting from uterine trauma related to chronic perforation of the IVC by an infrarenal filter, initially placed in a nonpregnant woman of childbearing age. A 36-year-old nonpregnant woman was treated with chronic anticoagulation therapy (AT) because of recurrent episodes of pulmonary embolism (PE). She developed a retroperitoneal hemorrhage due to warfarin toxicity, at which point, an infrarenal Trapease IVC filter was placed. Indefinite AT with low-molecular-weight heparin was later initiated. Chronic perforation of the IVC by the filter was incidentally noted 2 years later. Filter removal by percutaneous means was contraindicated, and given her asymptomatic status, operative removal was not offered. One year later, at age 39, she became pregnant. At an estimated intrauterine pregnancy age of 24 weeks, after physical activity, the patient developed sudden, extreme abdominal and back pain with associated dyspnea. A pulmonary computed tomography angiogram demonstrated no PE but showed free intraperitoneal fluid. She became hemodynamically unstable, concurrent with dramatic fall in fetal heart rate. Laparotomy and caesarean section were immediately performed, but the fetus was not salvageable. Bleeding was noted from a laceration to the dome of the uterus and was closed with chromic suture. A tear was noted in the peritoneal membrane overlying the filter, with barbs and vertical struts of the filter freely exposed. The vertical struts and barbs of the filter were removed, but due to instability, complete removal of the filter and IVC reconstruction was not deemed safe. Instead, the filter-bearing IVC was wrapped with a vascularized, transmesocolic omental flap. The patient's hospital course, 13 days, was complicated by intraperitoneal abscess (drained percutaneously) and wound infection. Complete healing was achieved at 10 weeks postoperatively. The patient is doing well at 4 months. Chronic AT with low-molecular-weight heparin has been continued, and the patient advised to avoid future pregnancies. Interaction between the gravid uterus and an infrarenally positioned IVC filter, presumed in the past to be a theoretic risk for IVC compression and thrombosis or perforation, is proven by this case to be a real risk. Although the filter in this case was a permanent type, use of an optional filter does not obviate this risk, because a large majority of optional filters are never removed. Societal consensus and device manufacturers should address this potential risk in guidelines for filter placement, positioning (preferably suprarenal), and emphasis on subsequent, planned filter retrieval when IVC filters are placed in nonpregnant women of childbearing age.