Although relatively rare, when Venous Thromboembolism (VTE) occur in pregnancy or the postpartum period, it can be with fatal consequence.  With a background occurrence rate of 0.6-1.8%, and occurrence along the spectrum of Deep Vein Thrombosis (DVT) to Pulmonary Embolism (PE), all members of the obstetrical team need to be aware of risk factors, common presentations and treatment/intervention strategies in order for the best possible outcome.   

Risk factors for VTE in obstetrics should be the basis of a screening tool.   Although there is agreement that universal prophylaxis for VTE does not have a place in obstetrics, there is not agreement regarding the need for even risk based screening in obstetrics despite a number of published tools.  Review of available screening tools will be part of the discussion to clarify their usefulness in selected populations.

With the rising rates of obesity and diabetes in our obstetrical population, coupled with the rising Cesarean section rates, reported in 2007 as 31.8%, the risk for VTE has never been higher.  Participants will be given tools to assist in implementing risk screening strategies for obstetrical populations or high risk obstetrical populations.

Ultimately when a PE is diagnosed, a complex, multidisciplinary response is essential to mitigate tissue damage and improve survivability.  A flowchart of multidisciplinary response will be reviewed with participants based on successful interventions leading to improved outcome in reported pulmonary embolism.

Case:

Mk is was a 31 year old Gravida 2 Para 1 patient at term presenting in spontaneous labor.  Fetal distress was diagnosed during labor requiring an emergency Cesarean section.  Infant was delivered without incident with Apgars of 8 at one minute and 9 at five minutes. 

 Approximately fifteen hours post Cesarean section, the patient appeared to have a syncopal episode with resulting cardiac arrest.  Intensive resuscitative measures were begun including CPR and fluid resuscitation.  On trans-esophageal echo, a massive saddle embolus was seen in the right ventricle, across the tri-cuspid valve and into the pulmonary artery.    Patient initially survived surgical embolectomy with complete cardiac bypass.  However, the patient was diagnosed with absent brain stem function and clinical brain death approximately 72 hours post intervention after multi-system failure.

Conclusion:

Although all obstetric patients do not require prophylaxis for VTE, there is a need for risk stratification for VTE in high risk populations.  It is imperative that obstetrical providers review implementation of risk based intervention criteria for VTE.

Keywords:

Pulmonary embolism, venous thromboembolism