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TEMPLATE DESIGN © 2008 www.PosterPresentations.com Management Challenge of Thrombophilia in Pregnancy-Case Report Dr. Gabriel Onyeka Ekekwe, Dr. Tempest Nicola, Mrs. Sandhya Rao St Helens & Knowsley Teaching Hospitals NHS Whiston Hospital, Warrington Road, Prescot, L35 5DR I ntroduction The risk of thromboembolism is increased significantly in pregnancy. The risk is further increased in patients with thrombophilia. Therefore, the use of anticoagulant in pregnancy is mandatory in these patients Low molecular weight heparin like clexane is the first line anticoagulant in pregnancy (1) Bleeding complications are rare with the use of clexane in pregnancy (1) However, when bleeding occurs it pose a management dilemma as in the case report presented. Retrievable vena cava filters has been found to be a safe alternative as was used in our patient(2,3) Case Report The patient is a 33 year old G3P2 (Two previous caeserean sections, last section was 8 years ago) She is a known thrombophilia (Heterozygous prothrombin gene mutation) with strong positive family history Her father and brother died of heart attack and pulmonary embolism at the age of 37 and 30 years respectively She smokes about 10 sticks of cigarrettes a day Her BMI was 38kg/m2 She has had three previous episodes of major thromboembolic events. The last episode was a saddle pulmonary embolism 4 years ago (see CTPA showing saddle embolus) Her long term Warfarin treatment was change to clexane (dose of clexane at1mg/kg x patient’s weight of 114kg=114mg in two divided doses) at 8 weeks gestation when USS confirmed intrauterine viable pregnancy She opted to continue with the pregnancy as the risk of fetal anomaly was perceived to be small She presented with massive broad ligament hematoma at 22 week gestation, hence the management challenge (see USS showing haematoma) Clexane was discontinued following consultation with the Haematologist A retrievable vena cava filter was inserted She had a favourable pregnancy out come. She had an elective caesarean section and bilateral tubal ligation (previous two c-sections) at 36 weeks gestation. Baby birth weight was 3.195kg Discussions The use of anticoagulant in pregnancy is mandatory in patients with thrombophilia Low molecular weight heparin like clexane is the first line anticoagulant in pregnancy (1) Clexane pose minimal risk of bleeding complication However, it did occur in our patient and was discontinued A retrievable VCF was then inserted Anatomic consideration makes infrarenal VCF technically difficult in pregnancy. However, infrarenal VCF was successfully inserted in our patient Suprarenal VCF offers an easier alternative, however, its potential thrombogenicity with possible renal compromise demand caution with this approach(4) Conclusions Retrievable VCF is safe alternative to anticoagulant treatment for pregnant women with increased risk of thromboembolism that are intolerant or for some reasons unsuitable for anticoagulant treatment It should also be considered in patient with thromboembolism despite adequate anticoagulant treatment References 1. Royal College of Obstetricians and Gynaecologists. ‘The Acute Management of Thrombosis and Embolism during Pregnancy and Puerperium’, Green top Guideline No. 37b, London: RCOG Press, 2007 2. Cipolla, J. et al (2008) ‘Complications of vena cava filters: A comprehensive clinical review’, OPUS 12 Scientist, vol. 2 (2); pp. 11- 24. 3. Gupta, S., Ettles, D.F., Robinson, G.J., and Lindow, S.W. (2008) ‘Inferior vena cava filter use in pregnancy: preliminary experience’, BJOG, vol. 115 (6); pp. 785-788. 4. Greenfield, L.J., Cho, K.J., Proctor, M.C., Sobel, M., Shah, S., and Wingo, J. (1992) ‘Late results of suprarenal Greenfield vena cava filter placement’, Arch Surg. 127; pp. 969-973.
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