Catheter-directed thrombolysis for the management of postpartum deep venous thrombosis

Postpartum ovarian vein thrombosis with left renal venous infarction after vaginal delivery

A primipara in her late 20s presented with abdominal pain and pain in the left flank 14 days after a ventouse delivery. She was treated with antibiotics, antiemetics and analgesics with the initial differential diagnosis of cystitis, pyelonephritis or nephrolithiasis. Despite the treatment, the patient experienced increased colic pain and nausea. An ultrasound showed an enlarged left kidney, suggesting pyelonephritis, and thereby, the antibiotic treatment was adjusted accordingly. Despite additional pain medication, pain relief could not be achieved. The diagnosis of ovarian venous thrombosis was considered, and an abdominal CT scan confirmed the diagnosis. The patient was treated with anticoagulant therapy. Hypercoagulability work-up revealed a heterozygous mutation of the Factor V Leiden. Our patient awaits a haematologic follow-up.

Postoperative Coagulation State Predicts Deep Vein Thrombosis After Cesarean Section in Elderly Pregnant Women

Introduction

We aimed to evaluate the risk factors for the development of deep vein thrombosis (DVT) within one month after delivery in pregnant women of advanced maternal age undergoing cesarean section and explore the predictive value of fasting coagulation indicators in relation to the development of DVT.

Methods

A total of 176 eligible postpartum women were included in this study. Sixty-seven cases developed DVT within one month after delivery (DVT group), while 109 cases did not experience DVT (NDVT group). Within 24 hours after cesarean section, fasting coagulation indicators are measured. Coagulation system analysis was performed using the STA-R Evolution fully automated coagulation analyzer.

Results

The women who developed DVT were found to be older, had a higher proportion of women with previous childbirth experiences, and had a higher proportion of women with comorbidities. Our results revealed significant differences in the levels of activated partial thromboplastin time and prothrombin time between the NDVT group and the DVT group. In contrast, the DVT group displayed significantly higher levels of D-dimer, plasma fibrinogen and platelet count when compared to the NDVT group. The AUC for the combined test model was substantially higher compared to individual parameters.

Discussion

Multiple parameters of the postoperative coagulation state in the combined test model provided a more accurate prediction of DVT occurrence in elderly pregnant women after cesarean section.

Catheter-Directed Thrombolysis for Postpartum Deep Venous Thrombosis

Venous thromboembolism is a major concern during pregnancy as well as in the postpartum period. In acute proximal deep venous thrombosis, endovascular recanalization with locally administered thrombolytic agents has evolved as therapeutic alternative to anticoagulation alone. However, data on the bleeding risk of thrombolysis in the postpartum period is limited. We addressed the key clinical question of safety outcomes of catheter-directed thrombolysis (CDT) in the peri- and postpartum period. Therefore, we performed a non-exhaustive literature review and illustrated the delicate management of a patient with postpartum acute iliofemoral thrombosis treated with CDT and endovascular revascularization with thrombectomy, balloon angioplasty and stenting.

Ovarian vein thrombosis in the postnatal period

Although ovarian vein thrombosis (OVT) is classically considered a puerperal pathology, it can also occur in nonpuerperal settings such as endometritis, pelvic inflammatory disease, Crohn's disease, pelvic or gynaecological surgeries and thrombophilia. Hypercoagulation conditions such as antiphospholipid syndrome, systemic lupus erythematosus, factor V Leiden and protein C and S deficiency are all recognised risk factors. It is also a known complication during pregnancy often presenting with fever and lower abdominal pain within weeks after delivery. Its incidence is exceedingly rare, occurring in 0.05% of all pregnancies that result in live births and peaking around 2-6 days after delivery. Its preferential involvement of the right ovarian vein may be explained by the compression of the inferior vena cava and the right ovarian vein due to dextrorotation of the uterus during pregnancy. Furthermore, antegrade flow of blood and multiple incompetent valves in the right ovarian vein favours bacterial infection. Complications may include sepsis and thrombus extension to the inferior vena cava or left renal vein and rarely, pulmonary embolism. The authors present the case of a 27-year-old woman with lower abdominal pain 5 weeks after an elective caesarean section. Although the diagnosis of postpartum endometritis was initially considered, a CT suggested a right OVT. She commenced treatment with low-molecular weight heparin. A high index of clinical suspicion is required in order to establish the diagnosis of this rare cause of abdominal pain, which can mimic an acute abdomen.

Postinterventional antithrombotic management after venous stenting of the iliofemoral tract in acute and chronic thrombosis: A systematic review

Venous stenting has become a common treatment option for central deep venous outflow obstructions and postthrombotic syndrome. Following successful recanalization and stenting, stent patency is endangered by in-stent thrombosis and recurrent venous thromboembolism. Antithrombotic therapy might reduce patency loss. This systematic review summarizes the literature on antithrombotic therapy following (post)thrombotic venous stenting. A systematic PubMed, MEDLINE, EMBASE, and Cochrane search was performed for studies addressing antithrombotic therapy prescribed following venous stenting of the iliofemoral tract indicated by acute or chronic thrombotic pathology. A total of 277 articles was identified of which 64 (56 original studies) were selected. Overall, a mean primary patency rate of 82.3% was seen 1 year after the intervention, which decreased to 73.3% after 2 years. In the majority (43 of 56 studies, 77%), treatment was based on use of vitamin K antagonists, either with (18%) or without (59%) use of antiplatelet drugs. Only two studies (4%) directly assessed the effect of antithrombotic therapy on treatment outcomes. The impact of postinterventional antithrombotic therapy on stent patency remains unknown because of limited and insufficient data available in current literature. Further clinical research should more clearly address the role of antithrombotic therapy for preservation of long-term patency following venous stenting.

Ovarian Vein Thrombosis: A Narrative Review

Ovarian vein thrombosis (OVT) is a rare type of venous thromboembolism. The most common risk factors for OVT include pregnancy, oral contraceptives, malignancies, recent surgery, and pelvic infections; however, in 4 to 16% of cases, it can be classified as idiopathic. Most of the available information regards pregnancy-related OVT, which has been reported to complicate 0.01 to 0.18% of pregnancies and to peak around 2 to 6 days after delivery or miscarriage/abortion. The right ovarian vein is more frequently involved (70-80% of cases). Clinical features of OVT include abdominal pain and tenderness, fever, and gastrointestinal symptoms. The most typical finding is the presence of a palpable abdominal mass, although reported in only 46% of cases. OVT can be the cause of puerperal fever in approximately a third of women. Ultrasound Doppler is the first-line imaging, because of its safety, low cost, and wide availability. However, the ovarian veins are difficult to visualize in the presence of bowel meteorism or obesity. Thus, computed tomography or magnetic resonance imaging is often required to confirm the presence and extension of the thrombosis. In oncological patients, OVT is often an incidental finding at abdominal imaging. Mortality related to OVT is nowadays low due to the combination treatment of parenteral broad-spectrum antibiotics (until at least 48 hours after fever resolution) and anticoagulation (low-molecular-weight heparin, vitamin K antagonists, or direct oral anticoagulants). Anticoagulant treatment duration of 3 to 6 months has been recommended for postpartum OVT, while no anticoagulation has been suggested for incidentally detected cancer-associated OVT.

American Society of Hematology 2018 guidelines for management of venous thromboembolism: venous thromboembolism in the context of pregnancy

BACKGROUND

Venous thromboembolism (VTE) complicates ∼1.2 of every 1000 deliveries. Despite these low absolute risks, pregnancy-associated VTE is a leading cause of maternal morbidity and mortality.

OBJECTIVE

These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and others in decisions about the prevention and management of pregnancy-associated VTE.

METHODS

ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations.

RESULTS

The panel agreed on 31 recommendations related to the treatment of VTE and superficial vein thrombosis, diagnosis of VTE, and thrombosis prophylaxis.

CONCLUSIONS

There was a strong recommendation for low-molecular-weight heparin (LWMH) over unfractionated heparin for acute VTE. Most recommendations were conditional, including those for either twice-per-day or once-per-day LMWH dosing for the treatment of acute VTE and initial outpatient therapy over hospital admission with low-risk acute VTE, as well as against routine anti-factor Xa (FXa) monitoring to guide dosing with LMWH for VTE treatment. There was a strong recommendation (low certainty in evidence) for antepartum anticoagulant prophylaxis with a history of unprovoked or hormonally associated VTE and a conditional recommendation against antepartum anticoagulant prophylaxis with prior VTE associated with a resolved nonhormonal provoking risk factor.

Endovascular treatment of iliofemoral deep vein thrombosis in pregnancy using US-guided percutaneous aspiration thrombectomy

PURPOSE

We aimed to describe ultrasonography (US)-guided percutaneous aspiration thrombectomy in pregnant women with iliofemoral deep vein thrombosis.

METHODS

This study included nine pregnant women with acute and subacute iliofemoral deep vein thrombosis, who were severe symptomatic cases with massive swelling and pain of the leg. Patients were excluded from the study if they had only femoropopliteal deep vein thrombosis or mild symptoms of deep vein thrombosis. US-guided percutaneous aspiration thrombectomy was applied to achieve thrombus removal and uninterrupted venous flow. The treatment was considered successful if there was adequate venous patency and symptomatic relief.

RESULTS

Complete or significant thrombus removal and uninterrupted venous flow from the puncture site up to the iliac veins were achieved in all patients at first intervention. Complete relief of leg pain was achieved immediately in seven patients (77.8%). Two patients (22.2%) had a recurrence of thrombosis in the first week postintervention. One of them underwent a second intervention, where percutaneous aspiration thrombectomy was performed again with successful removal of thrombus and establishment of in line flow. Two patients were lost to follow-up after birth. None of the remaining seven patients had rethrombosis throughout the postpartum period. Symptomatic relief was detected clinically in these patients.

CONCLUSION

Endovascular treatment with US-guided percutaneous aspiration thrombectomy can be considered as a safe and effective way to remove thrombus from the deep veins in pregnant women with acute and subacute iliofemoral deep vein thrombosis.

Catheter-directed thrombolysis in management of postpartum lower limb deep venous thrombosis - A case series

Deep vein thrombosis (DVT) is a major health problem in pregnancy and postpartum period. Catheter-directed thrombolysis (CDT) is safe and effective in the management of symptomatic DVT. Value of CDT in postpartum DVT is not fully evaluated. We describe five patients presenting with acute iliofemoral DVT in their early postpartum period who were treated with mechanical thromboaspiration and CDT. The CDT was done using streptokinase infusion and unfractionated heparin. Percutaneous angioplasty was done in patients with symptomatic residual lesion following thrombolysis. Patients were discharged with oral anticoagulant and compression stockings. This approach was successful in all five cases. Percutaneous endovascular therapy using CDT, mechanical thromboaspiration, and balloon angioplasty is safe and effective in iliofemoral DVT in postpartum period.

Catheter-Directed Thrombolysis Is a Safe and Alternative Therapeutic Approach in the Management of Postpartum Lower Limb Deep Venous Thrombosis

Deep vein thrombosis (DVT) is a major health problem in pregnancy and postpartum period. Catheter-directed thrombolysis (CDT) is safe and effective in management of symptomatic DVT. Value of CDT in postpartum DVT is not fully evaluated. We describe five patients presenting with acute iliofemoral DVT in their early postpartum period who were treated with mechanical thromboaspiration and CDT. The CDT was done using streptokinase infusion and unfractionated heparin. Percutaneous angioplasty was done in patients with symptomatic residual lesion following thrombolysis. Patients were discharged with oral anticoagulant and compression stockings. This approach was successful in all four cases. Percutaneous endovascular therapy using CDT, mechanical thromboaspiration, and balloon angioplasty is safe and effective in iliofemoral DVT in postpartum period.

Ultrasound-accelerated catheter-directed thrombolysis for the management of postpartum deep venous thrombosis

Pregnancy and the postpartum period are associated with an increased risk of venous thromboembolism, which remains an important cause of maternal morbidity and mortality. Although oral or systemic anticoagulation therapy may minimize thrombus propagation, it remains ineffective in removing thrombus burden and consequently does not prevent post-thrombotic syndrome. A novel technique, ultrasound accelerated catheter directed thrombolysis (UACDT), has been developed to rapidly and completely resolve thrombus. While pregnancy and the postpartum period are generally considered as contraindications for thrombolysis, we demonstrate in this case study the safety and effectiveness of using UACDT to treat symptomatic, postpartum, iliofemoral deep vein thrombosis after only an overnight infusion.

Acute right lower quadrant abdominal pain as the presenting symptom of ovarian vein thrombosis in pregnancy

Ovari an vein thrombosis (OVT) is an uncommon, life-threatening complication of pregnancy. OVT clinical presentation is similar to that of acute appendicitis, and the latter is therefore the suspected diagnosis in most cases. We describe a case of a 36-year-old woman experiencing deep vein thrombosis and pulmonary embolism during the course of pregnancy and presenting to the emergency department with sudden pain in the right lower quadrant and severe abdominal pain. This case illustrates the difficulty in diagnosing OVT, which should be considered in any pregnant woman with unexplained lower abdominal pain suggestive of acute appendicitis.

Surgical treatment of ovarian vein thrombosis

Ovarian vein thrombosis is a rare but serious condition that may cause sepsis in the postpartum patient or may be associated with thrombosis of the inferior vena cava or renal vein. A 30-year-old woman presented 2 weeks postpartum with sudden onset of dyspnea and rightsided pleuritic chest pain. She was diagnosed with a large pulmonary embolus and thrombosis of the right ovarian vein. After failure of percutaneous embolization of the right ovarian vein, the patient underwent open surgical excision of the right ovarian vein. The management of ovarian vein thrombosis may involve systemic anticoagulation, antibiotics, thrombolysis, open surgical treatment, or a combination of these.