Postpartum Cerebral Venous Thrombosis Research Articles

Unilateral Exophthalmia Revealing Postpartum Thrombophlebitis

Introduction: Cerebral thrombophlebitis of the peripartum is a rare entity but its occurrence is serious and can compromise the vital prognosis. The clinical picture is variable, which makes early diagnosis difficult. Patients and Methods: We report the case of a 28-year-old patient, on oral contraception for 3 years, with no previous history; who presented rapidly progressive bilateral visual acuity loss associated with headaches. The examination revealed a painless exophamia of the left eye without motor deficit, a slight chemosis with subconjunctival venous vasodilatation, associated with a bilateral papillary edema confirmed by OCT. CT scan showing a cerebral thrombophlebitis of the superior longitudinal sinus extended to the jugular vein with slight cerebral edema. The patient was immediately admitted to the intensive care unit and put on heparin therapy and additional immunological tests. Discussion: Pregnancy and postpartum increases the risk of thrombotic events. The most common cause in women of childbearing age is hypercoagulability, associated with the postpartum period, pregnancy, or oral contraceptives which is the case of our patient. Clinical symptoms are very polymorphic. The main thing is to think about it in order to make an early diagnosis. The positive diagnosis is neuroradiological. Improved diagnostic methods and consequent earlier treatment have markedly improved the prognosis of CVT in recent year. Conclusion: Postpartum cerebral venous thrombosis is a rare but serious pathology. The clinical diagnosis is not easy because of the clinical polymorphism, it is necessary to know how to think about it even in front of purely ophthalmological signs and to ask for neuro-radiological examinations to confirm it. The prognosis remains good if the diagnosis is made in time and if the treatment is started early.

Abstract WMP85: Postpartum Risk Of Cerebral Venous Thrombosis

Background: The postpartum state is associated with a heightened risk of thrombosis. The duration of heightened risk for postpartum cerebral venous thrombosis (CVT) is uncertain. Methods: Using claims data from the Healthcare Cost and Utilization Project (HCUP) from all emergency departments and acute care hospitalizations in Florida from 2005-2015 and New York from 2006-2015, we identified women aged ≥18 years old who were hospitalized for labor and delivery. CVT was ascertained using previously validated International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), diagnosis codes. For women with multiple labor-related hospitalizations during a single 40-week period, we excluded cases of false labor by identifying delivery as the latest hospitalization during that time. Patients with claims for CVT before their first recorded delivery, and women with a second delivery during the follow-up period were also excluded. We compared the likelihood of a first-ever recorded CVT during postpartum days 0-41 compared with the same period 1 year later. We repeated this crossover-cohort analysis for consecutive 6-weeks periods after delivery, as compared with the corresponding 6-week period 1 year later. We used McNemar's to calculate odds ratios for each 6-week interval. Results: Among the 1,406,447 women with a first recorded delivery, the risk of CVT was markedly higher within the 6 weeks after delivery than in the same period 1 year later (22 versus 3 CVTs per million deliveries). This corresponded to an absolute risk difference of 19 events per million (95% confidence interval [CI], 11-27) and an odds ratio of 10.0 (95% CI, 3.1-51.2). There was no significant increase in the risk of CVT during the period of 7 to 12 weeks after delivery as compared with the same period 1 year later with an absolute risk difference of 6.0 events (95% CI, 0-11) per million deliveries and an odds ratio of 3.0 (95% CI, 0.9-12.8). Conclusion: There appears to be a heightened risk of CVT for 6 weeks after delivery.

Case report: postpartum cerebral venous thrombosis misdiagnosed as postdural puncture headache

BackgroundCerebral venous thrombosis can be a fatal complication of the postpartum period. Pregnancy is known to be a risk factor for thromboembolism in itself.Case presentationA normal spontaneous vaginal delivery was planned for a 20-year-old primigravida patient with patient-controlled epidural analgesia. Next morning, the patient complained of an occipital headache. An epidural blood patch was performed for diagnostic and therapeutic purpose with 10 ml of autologous blood. That night, she had an episode of seizures. Endotracheal intubation was done to secure the airway. She was transferred to an intensive care unit. Brain CT angiography and MRI showed superior sagittal sinus thrombosis with acute infarct and mild subarachnoid haemorrhage. For cerebral venous thrombosis treatment, heparin was injected and for intracranial pressure control, a hypertonic solution was injected. Despite this medical treatment, intracranial pressure continued to rise. The next day, her mental state changed to stupor. Emergency decompressive craniectomy was performed. Her mental state improved rapidly after surgery. A week later, she was transferred to a general ward. Her health recovered and she was discharged.ConclusionsWe experienced postpartum cerebral venous thrombosis misdiagnosed as postdural puncture headache. We hope that this case report would be helpful in situation which a postpartum young woman complains severe headache in spite of management for headache including autologous epidural blood patch.

Акушерские причины материнской смертности. Результаты патологоанатомических исследований

Objective. To study the main causes of maternal mortality and to determine the role of obstetrical pathologies based on the findings of pathoanatomical autopsies. Materials and methods. The study included 42 autopsy findings, we studied medical documentation, autopsy records of deceased pregnant and parturient women. The most common causes of mortality (n = 29), according to the latest revision of ICD-10, were analyzed in detail. The general clinical and morphological examination was performed. Results. In Moscow, more than half of cases in the structure of maternal mortality refer to obstetrical pathologies. The most significant role belongs to preeclampsia and eclampsia (28.6%), they are in most cases characterised by an atypical clinical course and a specific pathomorphological picture. The second place is taken by massive pulmonary embolism (9.5%), the third place belongs to maternal shock during labour (7%) and the fourth place is shared by intrapartum infection (obstetrical sepsis), complications associated with obstetrical operative intervention and procedures, postpartum cerebral venous thrombosis, amniotic fluid embolism, postpartum cardiomyopathy (4.8%). Conclusion. The leading position in the structure of maternal mortality due to obstetrical causes belongs to preeclampsia and eclampsia. This pathology requires a complex approach to diagnosis and treatment, and postmortem verification of diagnosis should be confirmed by morphological examination with the use of immunohistochemical reactions. Key words: maternal mortality, obstetric pathology, preeclampsia and eclampsia, pulmonary embolism, maternal shock, obstetrical sepsis

Headaches after a recent pregnancy need an MRI to rule out cerebral thrombosis

Cerebral venous thrombosis (CVT) is a rare but serious complication of pregnancy and postpartum. It is characterized by a misleading symptomatology and the diagnosis must be evoked in the presence of persistent headache after delivery. MRI is the gold standard imaging exam for the diagnosis. Treatment is based on anticoagulation therapy. Functional prognosis is improved if diagnosis is promptly made and treatment started. We report the case of a 25-year-old woman with a delay diagnosis of postpartum cerebral venous thrombosis. The evolution was marked by severe neurological sequelae. We emphasize the interest of imaging in the early diagnosis of this pathology.

61 DAYS ON VV ECMO: A CULTURAL SHIFT TOWARDS PROLONGED ECMO DURATION

SESSION TITLE: Critical Care 5 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: ECMO (Extracorporeal Membrane Oxygenation) is a last resort intervention that is reserved for Acute Respiratory Distress Syndrome (ARDS) that does not respond to conventional treatment. The mean duration for ECMO in the Extra Corporeal Life Support Organization (ELSO) registry is 7-10 days1. However there have been cases reports where patients have survived over 100 days on ECMO2,3. The authors present a very complex case where they were challenged multiple times facing the issue of futility of care in the setting of prolonged ECMO. CASE PRESENTATION: A 47 year old male with no significant past medical history presented to the ED with shortness of breath found to be tachypnic (RR>52), saturating 84% on 6L of nasal cannula oxygen, hypotensive (88/48 mmHg), febrile (39.1C), and tachycardic (138 bpm). Pertinent physical exam findings were bilateral rhonci and use of accessory muscles to breathe. CXR revealed bilateral opacities worse on the right (Image 1) and was started on broad spectrum antibiotics for a Community Acquired Pneumonia. He was emergently intubated and met criteria for severe ARDS. Prone positioning was attempted, however did not improve oxygenation. Veno-venous (VV) ECMO (cannulas in right Internal Jugular and right Femoral vein) commenced. A CT Thorax showed worsening of the pneumonia (Image 2). The patient had a very complicated course, which included acute renal failure requiring Continuous Veno-Venous Hemofiltration (CVVH), hemothoraces and pneumothoraces requiring multiple chest tubes, multiple thoracotomies for the severe hemothoraces, and two cardiac arrests. The complications were treated appropriately but after 61 days of VV-ECMO the patient returned to native lung function and was discharged at baseline condition after rehabilitation. The ARDS was secondary to a superimposed Strep Pneumonia in the setting of Metapneumovirus. DISCUSSION: Determination of futility on ECMO is a sensitive topic with no clear guidelines. ELSO discusses futility of care and suggests no improvement with two weeks of ECMO should be considered futile unless a bridge to transplantation is planned1. This is not an official recommendation but one of guidance. There are multiple case reports of prolonged ECMO. For example a 28 year old female with no previous medical history survived 110 days of VV-ECMO for respiratory failure secondary to a postpartum cerebral venous thrombosis2. The longest successful duration of VV-ECMO was 265 days who was young and also did not have comorbidities3. The commonalities with these cases are that the patients are younger and lack comorbidities such as our case. CONCLUSIONS: With the increasing amount of case reports of successful prolonged VV-ECMO the paradigm seems to be shifting towards prolonged ECMO duration. The authors propose that the lung may have regenerative capabilities validating a prolonged course of VV-ECMO in young healthy patients. Reference #1: Pipeling MR, Fan E. Therapies for refractory hypoxemia in acute respiratory distress syndrome. JAMA. 2010;304:2521–2527 Reference #2: Strecker, T., Münch, F., & Weyand, M. (2012, August). One hundred ten days of extracorporeal membrane oxygenation in a young woman with postpartum cerebral venous thrombosis and acute respiratory distress syndrome. In Heart Surgery Forum (Vol. 15, No. 4, p. 180). Reference #3: Wiktor, A. J., Haft, J. W., Bartlett, R. H., Park, P. K., Raghavendran, K., & Napolitano, L. M. (2015). Prolonged VV ECMO (265 Days) for ARDS without technical complications. Asaio Journal, 61(2), 205-206. DISCLOSURES: No relevant relationships by Ravi Doobay, source=Web Response no disclosure on file for Dragos Manta; No relevant relationships by Amish Shah, source=Web Response

Cerebrovascular disease in South Asia - Part II: Risk factors and prevention.

In South Asian countries, conventional vascular risk factors like hypertension, diabetes mellitus, cardiac disease, smoking, obesity, atrial fibrillation are the dominant ones, while other aetiologies like rheumatic heart disease, infective meningitis-related infarcts and postpartum cerebral venous thrombosis also constitute a big fraction. This review discusses the evidence of prevalence of various risk factors in South Asian countries and possible measures to combat the rising burden of cerebrovascular disease. The last part of the review discusses prevention and identification of risk factors that are unique to or especially found in patient population of South Asia.

One Hundred Ten Days of Extracorporeal Membrane Oxygenation in a Young Woman with Postpartum Cerebral Venous Thrombosis and Acute Respiratory Distress Syndrome

Extracorporeal membrane oxygenation (ECMO) is often the last resort for serious acute respiratory distress syndrome (ARDS) when all non-invasive treatment options have failed to improve the patient's pulmonary condition. We present a successful long-term therapy with ECMO over 110 days in a 28-year-old woman. She developed postpartum cerebral venous thrombosis with severe respiratory insufficiency. Veno-venous ECMO rescued this young patient, allowing for full recovery.

Efficacy and safety of once daily low molecular weight heparin (tinzaparin sodium) in high risk pregnancy

Low molecular weight heparin (LMWH) is widely regarded as the anticoagulant treatment of choice for the prevention and treatment of venous thromboembolism during pregnancy. However, previous studies have demonstrated that the pharmacokinetic profiles of LMWH vary significantly with increasing gestation. Consequently, it remains unclear whether LMWH regimens recommended for use in nonpregnant individuals can be safely extrapolated to pregnant women. The aims of this study were to assess the safety and the efficacy of tinzaparin sodium (Innohep) administered only once daily during pregnancy. A systematic retrospective review identified a cohort of 37 high-risk pregnancies which had been managed using tinzaparin 175 IU/kg once daily. In 26 cases, the index pregnancy had been complicated by development of an acute venous thromboembolism (17 deep vein thrombosis and nine pulmonary embolism). For each individual, case notes were examined and data extracted using a predetermined questionnaire. No episodes of recurrent venous thromboembolism were identified amongst this cohort of pregnancies managed using once daily LMWH administration. However, two unusual thrombotic complications were observed, including a parietal infarct in one patient, and a postpartum cerebral venous thrombosis in another. Once daily tinzaparin was well tolerated, with no cases of heparin-induced thrombocytopaenia, symptomatic osteoporosis, or foetal malformations. Tinzaparin dose modification based upon peak anti-Xa levels occurred in 45% of the cases examined. The present study is the largest study to have examined the clinical efficacy of once daily LMWH for use in pregnant women at high risk of venous thromboembolism. Our data support the safety and efficacy of antenatal tinzaparin at a dose of 175 IU/kg. In order to determine whether this once daily regimen provides equivalent (or indeed greater) thromboprophylaxis to twice daily LMWH regimens during pregnancy will require highly powered direct comparative studies.

Stroke in Pregnancy

Although pregnancy-associated stroke is uncommon, the risk of stroke is greatly increased above the low baseline rate in young patients during late pregnancy and, even more so, during the puerperium. Stroke is a major contributor to the serious morbidity and mortality of pregnancy. The physiological hormonally mediated changes in circulation, vascular tissue structure, and coagulability, and the pathological state of pre-eclampsia-eclampsia contribute to this increased risk of stroke. Pregnancy-associated strokes are roughly evenly divided among hemorrhagic strokes, mainly from rupture of aneurysms and arteriovenous malformations (AVMs); ischemic strokes, mainly from late pregnancy and postpartum cerebral venous thrombosis; and strokes associated with pre-eclampsia-eclampsia, with a contribution from cardioembolism, especially in populations at risk from a high rate of underlying rheumatic valvular heart disease. Awareness of the types of stroke to expect during pregnancy will facilitate early diagnosis. This article discusses the pathogenesis of pregnancy-associated stroke, its epidemiology, and some diagnostic and therapeutic issues unique to pregnancy.

Pregnancy and Stroke

The risks of ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage are not increased in the 9 months of gestation except for a high risk in the 2 days prior and 1 day postpartum. The remaining 6 weeks postpartum also have an increased risk of ischemic stroke and intracerebral hemorrhage, though less than the peripartum period. Although there are some rare causes of stroke specific to pregnancy and the postpartum period, eclampsia, cardiomyopathy, postpartum cerebral venous thrombosis, and, possibly, paradoxical embolism warrant special consideration. The diagnostic and therapeutic approaches to stroke during pregnancy and the postpartum period are similar to the approaches in the nonpregnant woman with some minor modifications based on consideration of the welfare of the fetus. There is a theoretical risk of magnetic resonance imaging exposure during the first and second trimester but the benefit to the mother of obtaining the information may outweigh the risk. Available evidence suggests that low-dose aspirin (<150 mg/day) during the second and third trimesters is safe for both mother and fetus. Postpartum use of low-dose aspirin by breast-feeding mother is also safe for infant. While proper counseling is imperative, a history of pregnancy-related stroke should not be a contraindication for subsequent pregnancy.

Stroke in women of reproductive age: comparison between stroke related and unrelated to pregnancy

Pregnancy may increase the risk of stroke. However, few studies have compared strokes in women of reproductive age that occur in pregnancy or the puerperium (pregnancy-related stroke, PRS) with those unrelated to pregnancy. This study assesses risk factors and etiologies of stroke in these women based on relationship to pregnancy. From 1984 to 2002, all female patients 15 through 40 years of age with a first-ever stroke at National Taiwan University Hospital were included in this study. PRS was defined as patients who had stroke occurrence during pregnancy or within 6 weeks postpartum. Stroke was categorized as cerebral infarction (CI), cerebral hemorrhage (CH), or subarachnoid hemorrhage (SAH) and divided into subtype according to etiology. Risk factors and etiologies were compared for patients with PRS and stroke unrelated to pregnancy. We identified 49 patients with PRS, and 353 patients with stroke unrelated to pregnancy. There was no statistically significant difference in distribution of CI subtypes. Cerebral venous thrombosis (CVT) was more common in PRS than stroke unrelated to pregnancy (39% vs. 7%, P<0.001), and 73% of these cases occurred postpartum. Preeclampsia–eclampsia was an important cause of peripartum CH (37%), but not CI (4%). Among PRS cases, postpartum cerebral venous thrombosis and preeclampsia–eclampsia were the major causes of CI and CH, respectively.