COMPLEX VENOUS THROMBOEMBOLISM DECISION-MAKING IN POSTPARTUM PATIENT

ABSTRACT

Background May-Thurner syndrome and pregnancy are independent risk factors for the development of deep vein thrombosis (DVT). Emerging data suggests an association for venous thromboembolism (VTE) development in COVID-19 patients. Treatments for DVT vary and include thrombolysis, mechanical thrombectomy and long-term anticoagulation. We describe a unique case of this in a postpartum female. Case A 31 year old female G3P0121 and recent cesarean section 1 month ago presented with left lower extremity swelling, severely limited ambulation and 3+ edema of the left leg extending to the hip without any right leg edema. She was COVID-19 antibody positive. Occlusive DVTs were confirmed via venous duplex ultrasound and computed tomographic venography of the abdomen and pelvis, extending from distal inferior vena cava to the left popliteal vein. Decision-making Invasive venography confirmed the non-invasive imaging findings. After administering 12-14 mg of tissue plasminogen activator (tPA), multiple aspirations were performed using a rheolytic thrombectomy catheter. However persistent dense thrombus in the iliac and femoral veins remained, thus subsequent balloon angioplasty was performed but unsuccessful. Intravascular ultrasound confirmed the presence of May-Thurner syndrome at the junction of the left common iliac vein and the inferior vena cava. Finally an infusion catheter was placed for tPA. Within 48 hours, patient developed oliguric renal failure likely due to a combination of contrast-induced and pigment nephropathy requiring intermittent hemodialysis. Repeat ultrasound showed resolution of DVT along with improving edema and renal function. Warfarin was chosen for long-term anticoagulation due to renal failure and breast-feeding. Conclusion Pregnancy is a pro thrombotic state that may lead to VTE even in the postpartum period. Decision-making and treatment in these patients may be complex and require a multidisciplinary approach.