The Portosytemic Shunt: Liver Transplant Made Easier For The Anesthesiologist Authors: C.S. Scher, I Sanjeev Dalela, M.D., Devinder Verma, M.D., Jonathan Weinberg, M.D., Palanghat Radhakrishna, M.D., Joel Yarmush, M.D. and Joseph SchianodiCola, M.D. Anesthesiology, New York Methodist Hospital, Brooklyn, New York, United States, We present the case of a 29 week parturient who developed acute deep venous thrombosis followed by a pulmonary embolism subsequent to an open reduction and internal fixation of a fractured fibula under epidural anesthesia. Pregnancy is a hypercoagulable state. Long bone fracture places these patients at a high risk for potentially fatal complications like pulmonary embolism. At the same time, anticoagulation places these patients at risk of bleeding complications. This case demonstrates that an active multidisciplinary approach is required to prevent such complications in these high risk patients. A 27 year old patient with past medical history of migraine once or twice a year and childhood asthma had an episode of syncopy while at 25 weeks gestation with her second child. She fell and fractured her right fibula. The patient was evaluated at another hospital, and the fractured leg was put in a cast after a closed reduction. A few days later, she presented to our hospital with pain and swelling of the right lower extemity. At this time, she underwent an open reduction and internal fixation of the fracture. She received a combined spinal-epidural anesthetic for this procedure. The post-operative course was complicated by an episode of deep venous thrombosis followed by pulmonary embolism. She was placed on subcutaneous injections of enoxaparin. The patient started to complain of headache which felt different than her migraines. The headache started from the temples and radiated down her neck to her shoulders. Subsequently, the headache worsened and now was radiating down to her lumbar spine. The pain initially occurred when sitting or standing; she was headache free when supine. Now the headache was persistent and occured even when she was supine, but worsened on standing. She had anorexia and poor oral intake. She denied vision changes, weakness, numbness, vertigo, and tinnitus. She had no mental status changes or seizures. We were called to evaluate the patient for a possible post dural puncture headache (PDPH). We were unconvinced that she had a PDPH and requested an MRI of the head. MRI revealed a small subacute subdural hematoma. Enoxaparin was discontinued and she underwent an IVC filter placement under monitored anesthesia care and local anesthesia. She was transferred to the neurology unit for neuro checks, and was discharged home in satisfactory condition four days later. References:  Pulmonary embolism in pregnancy. Consensus and controversies; Benson MD; Department of Obstetrics and Gynecology, Northwestern University, Deefield, IL, USA. Benson MD  New directions in the diagnosis and treatment of pulmonary embolism in pregnancy; Cutts BA, Dasgupta D, Hunt BJ.;Thrombosis and Haemophilia Centre, Guy's and St Thomas' Trust, London, UK. Cutts BADasgupta DHunt BJ  Differential haemostatic risk factors for pregnancy-related deep-vein thrombosis and pulmonary embolism. A population-based case-control study; Bergrem A, Dahm AE, Jacobsen AF, Sandvik L, Sandset PM;Prof. Per Morten Sandset, Oslo University Hospital Rikshospitalet, Room B1.4032, Research Institute of Internal Medicine, Box 4950, N-0424 Oslo, Norway Bergrem ADahm AEJacobsen AFSandvik LSandset PM A case of Pulmonary Embolism in a 29 Week Parturient as a Consequence of a Fractured Fibula Resulting From a Fall