Mrs. S.A. is a 26-year old pregnant woman at 34 weeks of an IVF twin pregnancy who presented with left leg swelling and pain. She was diagnosed with left calf DVT. Despite anticoagulation therapy, she developed a recurrent massive left leg DVT. Given the increased risk of pulmonary embolism during delivery, doctors decided to place an IVC filter and perform a cesarean section. The procedures and pregnancy outcome were uncomplicated. Placement of an IVC filter can effectively reduce the risk of pulmonary embolism in high-risk pregnant patients with DVT.

2. Case Report
Personal Hx
• Mrs S. A
• 26 yrs .
• Married for 10 yrs.
• Primigravida
• IVF Twin Pregnancy - 34 weeks of gestation.
• Presented to Obstetric Emergancy Department on 07.01.2013.

3. Chief complain:
• Left leg swelling and pain.
Hx of present illness :
• One day prior to admission Pt complained of left
leg heaviness followed by swelling and pain.
Obstetric Hx
• PG pregnant at 34 weeks twin pregnancy after
successful IVF trial in Egypt .
• She had H/O primary infertility for 10 years due
to male factor.
• She had also failed of two IVF trial, one in Gaza
and the other one in Egypt.

4. Gynecologic Hx: Normal menarche & menses.
Past Hx : No DM, No HTN and No previous
history of DVT.
Drug Hx: Tonics, Omega -3, Nefedipine as a
tocolytic started at 32 Wk and Dexametasone at
32 Wk.
Family Hx : Father is hypertensive . No familial
history of DVT

5. Booking
• Up to 14 Wk  Egypt
• After 16 Wks  Primary Heath care + Private Clinic

6. on Admission
PHYSICAL EXAMINATION
Looks well, conscious , no dyspnea, no cyanosis
and no chest pain.
Vital Signs:
• T= 37.1oC BP= 110/70 mmHg
• RR= 16 bpm HR=88 bpm R bil

7. on Admission
• Chest: No crepitation
• Abdomen: extended with gravid uterus .FL± FT
• Cardiac: RRR, no murmur appreciated, no JVD.
• Lower Limb: Left culf mascle swelling, redness and
tenderness.
Right leg Left leg
Above the knee 41cm 42cm
Bellow the knee 53cm 58cm

8. In summary,,,
• Mrs S. A. is 26 yrs , PG, Pregnant at 34 wk IVF twins with
left calf muscle swelling, pain and tenderness .

9. The Impression
• Left leg DVT

10. PROGRESS IN HOSPITAL
• Admission
• IV Line
• Lab investigation
• Fetal wellbeing ( USS – CTG)
• Urgent Doppler USS

11. INVESTIGATIONS
• BG:BG: A+veA+ve
• CBC :CBC :
• Chemistry :Chemistry :
WBC HB PLT
10.300 11.1 210,000
AST ALT RBS urea Uric acid creatinin
23 19 95 14 3.1 0.6

12. Doppler USS
• Left leg popliteal DVT.

13. Hospital course
• CBC , CUA, KFT, LFT, Coagulation
profile
• Heparin SC protocol (Loading: 20000IU +
Maintenance: 15000 IU BID)
• B P chart
• Daily PTT

14. Clinical Progress
• After 2 days very good clinical improvement.
• PTT level = adequate anticoagulation
• Same dose Heparin continued (15000 BID-SC)
Initial
7/1/13
After 2days
9/7/13
After 1 week
14/1/13
Serial
PTT 32 48 52

15. Clinical Progress
• On 20/ 01//2013 while the patient was at 35w+6 Wk of
gestation, she developed generalized severe left leg
swelling and pain.
Urgent Re- Doppler USS  Massive popliteal and
femoral VT

16. Problem
• 1. Inspite of adequte of anticoagulation therapy we
are faced with a a case of recurrent massive left leg
DVT.
• 2. The patient is 36 wk, IVF twin pregnancy, a waiting
for cesarean section delivery in presence of massive
left popliteo-femoral DVT.

17. Quastions
• Is it safe to do pelvic surgery (CS) in
presence of acute massive DVT?
• What is the hazards?

18. VTE and Pulmonary embolism in pregnancy
• Pregnant women are at an increased risk
for venous thromboembolic disease (VTE)
• 1 in 1000 pregnancies
• The risk of DVT and subsequent pulmonary
embolism in pregnant women is six times higher
than in non-pregnant.
• Cesarean delivery > vaginal delivery
• Daily risk of PE and DVT highest following delivery
than antepartum.
• 43-60% of PE occur 4-6 weeks after delivery
• PE is the the most common cause of direct
maternal death.
• 2/100 000 pregnancies

19. Why is the risk greater in pregnancy?

20. Independent risk factors of a higher
VTE risk in pregnancy?
• Bed rest
• Multiparity
• Advanced maternal age (>35 y.o.)
• Overweight
• Personal or family history of VTE
• Preeclampsia

21. Quastions
• Is it safe to do pelvic surgery (CS) in
presence of acute massive DVT?
• What is the hazards?

22. Quastions
• Is it safe to do pelvic surgery (CS) in presence of acute
massive DVT?
NO
Because of increased risk of propagation of a
distal thrombus toward the pulmonary vessels
(Pulmonary Embolism).
• How to reduce this risk?

23. How To reduce maternal death in pregnancy due
to DVT and pulmonary embolism?
• Anticoagulation treatment should be started as soon
as a diagnosis is made.
• Placement of an inferior vena cava filter is a
feasible and effective choice when :
- recurrent thromboembolism occurs despite adequate
anticoagulation or
- when anticoagulation is contraindicated for
therapeutic or prophylactic indications.

24. Decision
• To shift heparin treatment from SC to IV
infusion ( 1200IU per hour)
• To place Inferior Vena Cava Filter
• To do elective CS

25. Why IVC Filter in our patient?
• The postpartum period is conceded to be the highest-
risk period for venous thromboembolism and
pulmonary embolism in pregnant patient.
• Our patient was considered to be at high risk of
intrapartum and postpartum pulmonary embolism.
• The risk of pulmonary embolism increases due to the
discontinuation of anticoagulation and the
hemodynamic changes accompanying the rapid
decompression of the venous system after delivery

26. IVC implantaton
EGH Cath Lab Dep. - 22/01/2013
Procedure: Cavogram was done via right femoral vein
( IVC – 25cm) then long sheet was inserted and IVC
filter ( cook celect vena cava filter, E2664200, ref:
IGTCFS-65-2-UNI-CELECT) was implanted in the IVC
below the rena veins without complications.
Team : Dr. Mohammed Habib , Dr Waeil Hijazi,
Dr. Hassan Zammmar, Dr. Eyad Saafeen.

27. IVC implantaton
EGH Cath Lab Dep. - 2/1/13

28. Facts about IVC Filters
• First reported by Greenfield in 1967.
• IVC filter placement in pregnancy was first
presented in 1973
• The procedure has been justified to reduce
the risk of significant recurrent pulmonary
embolism to 1% to 3% in the nonpregnant
population.
• Optional Filters (temporary - retrievable or
permanent)

29. Indications of IVC Filter in non-
pregnant patient
Confirmed DVT or pulmonary embolism with a
contraindication to or complication with heparin
therapy
 Recurrent pulmonary embolism despite adequate
anticoagulation.
Other relative indications include a free-floating
thrombus documented by means of Doppler
ultrasound imaging and the presence of extensive
iliac thrombosis that may result in pulmonary
embolism

30. Indications of IVC Filter in
pregnant patient
• In patients with DVT early in the first or second
trimester of pregnancy are in accord with those in
non-pregnant patients.
• For prophylactic prevention of intrapartum and
postpartum pulmonary embolism in term
pregnant patients with DVT of the lower
extremities

31. A- Indications
I- Absolute indications (proven VTE)
• 1. Recurrent venous thrombo embolism "VTE"
(Acute
• or chronic) despite adequate anticoagulation. 2.
• Contraindications to anticoagulation. 3.
• Complications of anticoagulation. 4. Inability to
• achieve/ maintain therapeutic anticoagulation.

32. A- Indications
II- Relative indications (proven VTE):
• 1. Ilio- caval DVT.
• 2. Large free- floating proximal DVT.
• 3.Difficulty establishing therapeutic anticoagulation.
• 4. Massive pulmonary embolism treated with thrombolysis/
thrombectomy.
• 5.Chronic PE treated with thromboendartrectomy.
• 6. Thrombolysis for iliocaval DVT.
• 7.VTE with limited cardiopulmonary reserve.
• 8.Recurrent PE with filter in place.
• 9.Poor compliance with anticoagulant medications.
• 10.High risk complication of anticoagulation (e.g., ataxia,
frequent falls).

33. A- Indications
III- Prophylactic indications (NO VTE, Primary
prophylaxis not feasible*)
• 1. Trauma patient with high risk of VTE.
• 2. Surgical procedure in a patient at high risk of VTE.
• 3. Medical condition with high risk of VTE.

34. B- Contraindications to filter
placement
• 1. No access route to the vena cava.
• 2. No location available in vena cave for placement of filter
* Primary prophylaxis not feasible as a result of high
bleeding risk, inability to monitor the patient for VTE.

35. Caesarean Section
• Heparin infusion stopped 5 hour before surgery
• Elective CS performed on 23/1/13
• Uneventful procedure
• Outcome  healthy 2 female baby, WT: 3 - 2.7kg
• Post CS after 8 hour Clexan 80 mg BID started
• Uneventful postoperative period
• On 26/1/13 warfarin 5mg Tb OD started, and after
3 days when INR raised > 2 Clexan treatment
discontinued.
• On 29/3/13 patient discharged on Warfarin 5mg
Tb OD treatment.

36. IVC filters: benefits and risks
Decousus, NEJM 2005
400 patients with proximal DVT, 50% with PE
Filter No filter p
PE at day 12 1% 5% 0.03
PE at 2 years 3% 6% NS
DVT at 2 years 21% 12% 0.02
Death 22% 21% NS
Major bleed 9% 12% NS

37. Retrievable IVC filters
• FDA approved
• Ideal for young patients with reversible PE risk factors
• Left in, they become permanent
– Current duration < 2 weeks

38. Thrombophilia gene mutation
Prothrombin Factor XIII ACE
Normal Normal Heterozygous
Antithrombin III Factor V Leiden MTHFR PAI-1 gene
Normal Normal Normal Heterozygous

39. Conclusion
• Pregnancy is a hypercoagulable status, associated with
increased risk of DVT and life threatening PE especially in
postpartum period.
• Time has come for a second thought about the role of bed rest
and thromboprophylaxis in IVF pregnant patients.
• IVC filter placement should be consider for patients with DVT
in term pregnancy who are at particularly high risk of
intrapartum and postpartum pulmonary embolism.
• IVC filters are an effective and safe method in the prophylaxis
and therapy of VTE in pregnancy, and this use right before
labor has been justified by several studies.
• Retrievable filters might reduce long-term complications.

40. Thank You