Reflexo disfórico da ejeção do leite: conhecimento e diferenciação com transtornos mentais puerperais entre ginecologistas e obstetras paranaenses / Dysphoric milk ejection reflex: knowledge and differentiation with puerperal mental disorders between gynecologists and obstetricians from Paraná

Objetivo: Identificar o conhecimento dos médicos ginecologistas e obstetras do Paraná sobre o reflexo disfórico da ejeção do leite e seus diagnósticos diferenciais. Métodos: Estudo observacional transversal com médicos ginecologistas e obste- tras associados ao Conselho Regional de Medicina do Paraná. A coleta de dados foi realizada por questionário online compreendendo perguntas de identificação do profissional, tempo de formação, conhecimento e experiência com reflexo disfóri- co da ejeção do leite, dificuldades de diferenciação entre os transtornos mentais puerperais, além da abordagem das questões psicológicas puerperais com as pa- cientes. Os resultados foram expressos por frequências e percentuais. Valores de p menores que 0,05 foram considerados significativos. Resultados: Entre os partici- pantes, 39,1% desconhecem o reflexo disfórico da ejeção do leite. Dos profissionais que já fizeram o diagnóstico, 72,4% apresentaram dificuldade em realizá-lo. Houve acerto majoritário em relação ao momento de ocorrência dos sintomas (90,6%) e tempo de duração (90,6%), mas deficiência no reconhecimento de todos os sin- tomas (3,1%), início das manifestações clínicas (12,6%) e tratamento (44%) pelos profissionais que conhecem o reflexo disfórico da ejeção do leite. Entre os especia- listas, 21,5% sentem-se capazes para diferenciar os três distúrbios e 24,1% têm difi- culdade na diferenciação entre as patologias. Apenas 65,5% dos médicos abordam as dificuldades emocionais na amamentação e, segundo 78,1% dos profissionais, poucas pacientes perguntam ou nunca perguntam sobre essas dificuldades. Con- clusão: O reflexo disfórico da ejeção do leite é uma condição pouco conhecida e confundida com outros transtornos mentais puerperais. É necessária maior divul gação sobre o tema entre os ginecologistas e obstetras, a fim de melhorar a assistência às puérperas, refletindo na persistência da amamentação e seus benefícios.

Objective: To identify the knowledge of gynecologists and obstetricians in Paraná about the dysphoric milk ejection re- flex and its differential diagnosis. Methods: Cross-sectional observational study was conducted with gynecologists and obstetricians associated in the Regional Council of Medicine of Paraná. Data collection was dove through an online question- naire with questions about professional identification, years of experience, knowledge and experience with the dysphoric milk ejection reflex, differentiation puerperal mental disorders difficulties, as well as the approach of postpartum psycholo- gical issues with patients. Results were expressed in frequen- cies and percentages. P values less than 0.05 were considered significant. Results: 39.1% of the participants unknown the dysphoric milk ejection reflex. Among the professionals who had diagnosed dysphoric milk ejection reflex, 72.4% reported difficulties in making the diagnosis. There was a high level of correct answers regarding the timing of symptoms (90.6%) and duration (90.6%), but deficiencies were observed in recognizing all symptoms (3.1%), onset of clinical manifestations (12.6%), and treatment (44%) by professionals who were familiar with dysphoric milk ejection reflex. 21.5% of specialists felt capab- le of differentiating between the three disorders, while 24.1% had difficulty in differentiating between the pathologies. Only 65.5% of doctors approach emotional difficulties in breastfee- ding and, according to 78.1% of professionals, few patients ask or never ask about these difficulties. Conclusion: Dysphoric milk ejection reflex is a condition that is poorly known and of- ten confused with other postpartum mental disorders. Greater awareness about this topic is necessary among gynecologists and obstetricians to improve care for postpartum women, lea- ding to the continuation of breastfeeding and its benefits.

Peripartum cardiomyopathy: A review.

Peripartum cardiomyopathy is a rare type of heart failure manifesting towards the end of pregnancy or in the months following delivery, in the absence of any other cause of heart failure. There is a wide range of incidence across countries reflecting different population demographics, uncertainty over definitions and under-reporting. Race, ethnicity, multiparity and advanced maternal age are considered important risk factors for the disease. Its etiopathogenesis is incompletely understood and is likely multifactorial, including hemodynamic stresses of pregnancy, vasculo-hormonal factors, inflammation, immunology and genetics. Affected women present with heart failure secondary to reduced left ventricular systolic function (LVEF <45%) and often with associated phenotypes such as LV dilatation, biatrial dilatation, reduced systolic function, impaired diastolic function, and increased pulmonary pressure. Electrocardiography, echocardiography, magnetic resonance imaging, endomyocardial biopsy, and certain blood biomarkers aid in diagnosis and management. Treatment for peripartum cardiomyopathy depends on the stage of pregnancy or postpartum, disease severity and whether the woman is breastfeeding. It includes standard pharmacological therapies for heart failure, within the safety restrictions for pregnancy and lactation. Targeted therapies such as bromocriptine have shown promise in early, small studies, with large definitive trials currently underway. Failure of medical interventions may require mechanical support and transplantation in severe cases. Peripartum cardiomyopathy carries a high mortality rate of up to 10% and a high risk of relapse in subsequent pregnancies, but over half of women present normalization of LV function within a year of diagnosis.

Postpartum Psychosis or Something Else?

Psychosis is a psychiatric emergency that affects up to 1 in 500 women postpartum and can result from various etiologies. We present a case vignette and review of the relevant literature to highlight the broad differential diagnosis of postpartum psychosis with atypical features. Recommendations for evaluation, diagnosis, and treatment of patients with complex neuropsychiatric symptoms in the postpartum period are discussed. This case of postpartum psychosis with malignant catatonia highlights the role of immunology in the development and treatment of postpartum psychosis and the need for future research to more accurately define the etiology and best tailor treatment.

Obstetric hemorrhage risk assessment tool predicts composite maternal morbidity.

Obstetric hemorrhage is one of the leading preventable causes of maternal mortality in the United States. Although hemorrhage risk-prediction models exist, there remains a gap in literature describing if these risk-prediction tools can identify composite maternal morbidity. We investigate how well an established obstetric hemorrhage risk-assessment tool predicts composite hemorrhage-associated morbidity. We conducted a retrospective cohort analysis of a multicenter database including women admitted to Labor and Delivery from 2016 to 2018, at centers implementing the Association of Women's Health, Obstetric, and Neonatal Nurses risk assessment tool on admission. A composite morbidity score incorporated factors including obstetric hemorrhage (estimated blood loss ≥ 1000 mL), blood transfusion, or ICU admission. Out of 56,903 women, 14,803 (26%) were categorized as low-risk, 26,163 (46%) as medium-risk and 15,937 (28%) as high-risk for obstetric hemorrhage. Composite morbidity occurred at a rate of 2.2%, 8.0% and 11.9% within these groups, respectively. Medium- and high-risk groups had an increased combined risk of composite morbidity (diagnostic OR 4.58; 4.09-5.13) compared to the low-risk group. This established hemorrhage risk-assessment tool predicts clinically-relevant composite morbidity. Future randomized trials in obstetric hemorrhage can incorporate these tools for screening patients at highest risk for composite morbidity.

An Australian perspective on treating perinatal depression and anxiety: a brief review of efficacy and evidence-based practice in screening, psychosocial assessment and management.

Australia is at the forefront of developing screening practices, interventions and national public health policy for perinatal women with depression and anxiety. For the last two decades Australian mental health experts and public health administrators have conducted population-wide feasibility studies on screening and incorporated these in national guidelines. This chapter outlines the wider evidence base supporting current Australian practice. Key recommendations include use of the Edinburgh Postnatal Depression Scale or the Patient Health Questionnaire-9 early in pregnancy and at 6-12 weeks postpartum, followed by psychosocial assessment. Positive depression screens need to be followed by diagnostic assessment, and clear treatment pathways must be available. Milgrom and colleagues' cognitive behavioural treatment is the only Australian program with a solid evidence base demonstrating its effectiveness for depression and associated anxiety. The face-to-face treatment has been further developed into an online program, MumMoodBooster, funded by the Federal government and available to Australian women.

Postpartum headache: A broader differential.

A 40-year-old female presented to the ED with a history of intermittent headaches since a vaginal delivery 8 days prior. Her pregnancy was unremarkable and was not complicated by pre-eclampsia. She did not present with signs or symptoms consistent with postdural puncture headache or pre-eclampsia. Her delivery was not complicated by hypotension or post-partum hemorrhage. By chance, she was found to be hyponatremic and admitted to internal medicine for further work-up. She was diagnosed with postpartum lymphocytic adenohypophysitis and treated with steroids. She was discharged with a steroid taper and had complete resolution on follow up. Lymphocytic hypophysitis (LH), or commonly known as autoimmune hypophysitis, is a rare inflammatory condition affecting the pituitary gland. Acute LH can result in sudden death as demonstrated in some case reports. The most common symptom in >50% of cases is headache. First-line pharmacological treatment consists of high-dose corticosteroids and is effective in reducing pituitary size and improving endocrine insufficiency in 75% of cases. LH is a potential cause of postpartum headache that can be easily screened for with history and routine bloodwork and has good outcomes with early intervention. LH should be added to the differential for postpartum headaches presenting to the emergency department and routine blood work should be considered for all postpartum headaches.

Pelvic Floor Sensations After the First Vaginal Delivery: A Qualitative Study.

OBJECTIVES: Current validated instruments to screen for pelvic organ prolapse and its sequelae address bulge symptoms, bowel and bladder changes, and sexual intimacy. However, sensitivity is lower in younger women, and there is no instrument specifically designed to screen in postpartum, primiparous women for early changes, that is, changes that may be noticed before the symptom of a bulge or signs of pelvic organ prolapse occur. Our goal was to elucidate early sensations of pelvic floor support changes in primiparous women after their first vaginal delivery. These could be the focus of future studies differentiating such sensations from a normal postpartum, aiding identification of women for further follow-up. METHODS: Using comparative focused ethnographic methods, we purposefully sampled and interviewed 17 multiparous women diagnosed with pelvic organ prolapse and 60 primiparous women, half Euro-American and half Mexican American, English or Spanish speaking. Audiotapes were transcribed and then translated. Using inductive coding and matrix analysis, we used constant comparison across transcript data and clustered coded data into body systems-level matrices to arrive at categories of early changes. RESULTS: We identified early changes by ethnic group in pelvic area sensations and bowel, bladder, and sexual function, including sensations not mentioned in extant questionnaires. CONCLUSIONS: Early changes may be distressing but difficult for women to introduce in a clinical conversation. Querying these changes may enhance patient-provider communication. Future research is needed to validate these items in questionnaires designed to identify women with persistent early changes that may lead to subsequent objective pelvic organ prolapse.

Conservative treatment of patients with bladder genital tract fistula: Three case reports.

INTRODUCTION: Most of the patients with bladder genital tract fistula recover with surgical treatment. In the present study, we aimed to assess conservative treatment strategies for bladder genital tract fistula. PATIENT CONCERNS: We reviewed 3 cases with bladder genital tract fistula who underwent treatment at our hospital from January to June 2017. Patient 1 underwent cesarean delivery, Patient 2 underwent total abdominal hysterectomy bilateral salpingo-oophorectomy (TAHBSO) and pelvic lymphadenectomy, and Patient 3 underwent extensive TAHBSO and pelvic lymphadenectomy. All 3 patients exhibited involuntary vaginal fluid outflow (average duration, 12.7 days; range, 7-21 days). DIAGNOSIS: Patient 1 was diagnosed as vesicouterine fistula by cystosonography and Patient 2, Patient 3 was diagnosed as vesicovaginal fistula by cystoscopy. INTERVENTIONS: All 3 patients underwent indwelling urinary catheterization. OUTCOMES: No vaginal fluid outflow could be observed after treatment of all 3 patients. CONCLUSION: Indwelling urinary catheterization should be administered for suitable patients as conservative treatment. If vesicouterine fistulas that are simple and have a diameter of <0.5 cm can be treated conservatively. If the condition does not resolve after 2 months, surgery should be considered.

Spontaneous renal fornix rupture in pregnancy and the post partum period: a systematic review of outcomes and management.

BACKGROUND: Spontaneous renal fornix rupture (SRFR) causing urinoma is an uncommon but serious condition in pregnancy. Limited information is available to describe the natural history and outcomes to guide appropriate treatment. The aim of this study was to determine the natural history and outcomes of SRFR to determine appropriate management recommendations. METHODS: A systematic review of literature databases was performed, using the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) checklist from 1950 - April 2020. Inclusion criteria included any urinary extravasation from the kidney or ureter during pregnancy, or in the 8 weeks following delivery, confirmed via imaging or surgery. Haematomas and non-confirmed cases were excluded. RESULTS: A total of 1579 records were originally identified, of which 39 case reports were appropriate for inclusion. SRFR was most commonly reported during the first pregnancy (72%), 19/30 during the third trimester and 9 in the post-natal period. All patients presented with pain, with haematuria positive on urine dipstick in only 36% of 26 reported cases. Ultrasound was the most frequently used imaging modality, resulting in a diagnosis in 42% of cases. All cases reported on treatment procedures including ureteric stents (46%), percutaneous drain (15%), conservative management (15%), nephrostomy (13%) and ureteral catherization (10%). Long term urological outcomes were positive, however women suffering SRFR were significantly more likely to undergo pre-term labour. CONCLUSION: While selected cases may be successfully managed conservatively, urinary diversion, through ureteric stents, should be considered the management of choice in these individuals. Clinicians should be mindful of an increased risk of premature delivery and its' associated negative fetal outcomes.

A systematic review of diagnosis and treatment of acute limb ischemia during pregnancy and postpartum period.

BACKGROUND: Acute limb ischemia (ALI) carries significant overall morbidity and mortality. Pregnant and postpartum women are physiologically hypercoagulable, but little is known about the impact of ALI in this cohort of patients. The goal of this systematic review was to gather available data on diagnosis and treatment of ALI during pregnancy and the postpartum period. METHODS: A systematic review of studies on patients with ALI during pregnancy and the puerperium was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three databases including PubMed MEDLINE, Embase, and Cochrane Library were queried. Manuscripts that provided data on diagnosis and treatment of ALI in pregnant and postpartum patients were included regardless of language or study design. Outcomes of interest included type of treatment for ALI (open and endovascular), morbidity, and mortality. RESULTS: Fourteen manuscripts of 6222 references were included with a total of 14 patients. The median age of patients was 31.5 years. Embolism, present in eight (57%) patients, was slightly more common than thrombosis. All patients had a pregnancy complication or concomitant medical condition that might have predisposed to arterial occlusion either directly or indirectly by leading to iatrogenic arterial injury; peripartum cardiomyopathy, the most common, occurred in six (43%) patients. Open surgery was the preferred treatment option in 11 (79%) patients, followed by anticoagulation alone. No endovascular procedures were described. One patient underwent major amputation on presentation, and an additional patient required major amputation for recurrent ALI. No deaths occurred. Twelve (86%) patients had complete recovery with no other ALI-associated sequelae. CONCLUSIONS: ALI is rare in pregnant and postpartum women despite their transient physiologic hypercoagulability and is almost uniformly associated with pregnancy complications. Open surgical revascularization or anticoagulation alone appears to have acceptable outcomes as most patients present with embolism or thrombosis without underlying systemic arterial disease.

Masa pélvica en la mujer puérpera. Presentación de caso / Pelvic mass in puerperal woman. Case presentation

El término infección puerperal se utiliza para describir cualquier infección bacteriana del aparato genital después del parto. Durante gran parte del siglo XX las infecciones puerperales, la preeclampsia y la hemorragia obstétrica formaron parte de la tríada letal de mortalidad materna. La ecografía, la resonancia magnética y la tomografía axial computarizada son la triada de elección para el diagnóstico del abdomen agudo en el puerperio. El mismo resulta difícil debido a factores intrínsecos y es entonces, cuando el radiólogo adquiere un papel crucial. Se presentó un caso de una mujer de 30 años, con 8 días de habérsele practicado una cesárea con un puerperio inmediato normal. Posteriormente presentó dolor abdominal, fiebre, escalofríos y masa palpable en fosa iliaca izquierda. Se practicaron técnicas de imágenes se plantea una masa ovárica izquierda, se realizó laparotomía exploradora y se concluyó como absceso ovárico (AU).

The term puerperal infection is used to describe any bacterial infection of the genital tract after delivery. During much of the twentieth century puerperal infections, preeclampsia and obstetric hemorrhage were part of the lethal triad of maternal mortality. Ultrasonography, magnetic resonance imaging and computed tomography are the triad of choice for the diagnosis of acute abdomen in the puerperium, which is difficult due to intrinsic factors and it is when radiologist plays a vital role. The authors present the case of a woman, aged 30 years, at the 8th day after undergoing a cesarean section with a normal immediate puerperium, who later presented abdominal pain (AU).

Perinatal psychological well-being in women with zero postnatal anxiety-depressive symptoms scores: a retrospective descriptive study.

Background: A total absence of psychological symptoms during pregnancy or postpartum period is not common. Although there are some considerations on zero scores detected by EPDS, no thorough analysis is currently present in the literature of the eventuality and meaning of a total absence of postpartum symptoms following the compilation of two or more self-report symptom questionnaires.Methods: In a sample of 960 Italian women, three groups of 31 subjects are defined retrospectively by scores on the EPDS-GHQ12: women with 'zero', 'lower', and 'higher' postnatal symptomatology. The psychological well-being of these groups was compared as detected in pregnancy and after childbirth by PWB questionnaire.Results: Higher and excessive scores in Environmental mastery dimension connote the profile of women with a total absence of postpartum anxiety-depression symptoms. Positive relations with other dimension were less characterising, but it should be noted as a distinctive trait in the 'zero' symptoms postnatal symptomatology group. In the same 'zero' group, the scores of the six PWB questionnaire dimensions - except Personal growth - are all higher than the scores obtained by women in the general population.Conclusion: The atypical self-reported perinatal mood condition present in the 'zero' symptoms group have currently unknown clinical significance.

Acute Stroke During Pregnancy and Puerperium.

BACKGROUND: Acute stroke during pregnancy or within 6 weeks of childbirth is devastating for the mother and her family, yet data regarding incidence and contemporary trends are very limited. OBJECTIVES: This study sought to investigate the incidence and outcomes of acute stroke and transient ischemic attack during pregnancy or within 6 weeks of childbirth in a large database. METHODS: The National Inpatient Sample was queried to identify women age ≥18 years in the United States with pregnancy-related hospitalizations from January 1, 2007, to September 30, 2015. Temporal trends in acute stroke (ischemic and hemorrhagic)/transient ischemic attack incidence and in-hospital mortality were extracted. RESULTS: Among 37,360,772 pregnancy-related hospitalizations, 16,694 (0.045%) women had an acute stroke. The rates of acute stroke did not change (42.8 per 100,000 hospitalizations in 2007 vs. 42.2 per 100,000 hospitalizations in 2015; ptrends = 0.10). Among those with acute stroke, there were increases in prevalence of obesity, smoking, hyperlipidemia, migraine, and gestational hypertension. Importantly, in-hospital mortality rates were almost 385-fold higher among those who had a stroke (42.1 per 1,000 pregnancy-related hospitalizations vs. 0.11 per 1,000 pregnancy-related hospitalizations; p < 0.0001). The rates of in-hospital mortality among pregnant women with acute stroke decreased (5.5% in 2007 vs. 2.7% in 2015; ptrends < 0.001). CONCLUSIONS: In this contemporary analysis of pregnancy-related hospitalizations, acute stroke occurred in 1 of every 2,222 hospitalizations, and these rates did not decrease over approximately 9 years. The prevalence of most stroke risk factors has increased. Acute stroke during pregnancy and puerperium was associated with high maternal mortality, although it appears to be trending downward. Future studies to better identify mechanisms and approaches to prevention and management of acute stroke during pregnancy and puerperium are warranted.

A screening and treatment programme to deal with perinatal anxiety and depression during the COVID-19 pandemic.

During a pandemic, pregnancy and the postnatal period are complicated by multiple factors. On the one hand, worries about one's own health and the health of loved ones, in particular of the newborn child, can increase the risk of some mental disorders, such as depression and anxiety in the pregnant woman. On the other hand, as happened for the COVID-19 epidemic in Italy, given the need for physical distancing, the maintenance of the social and family network, so important for new parents in the perinatal period, is lacking. In addition, health services are forced to reorganize their offerings to ensure maximum safety for their operators and patients. This work proposes a model of screening and treatment aimed at identifying women at risk and providing them with effective and safe treatment.

MOG-IgG myelitis coexisting with systemic lupus erythematosus in the post-partum setting.

BACKGROUND: Longitudinally extensive transverse myelitis (LETM) accompanying systemic lupus erythematosus (SLE) is often due to coexisting aquaporin-4-IgG seropositive neuromyelitis optica spectrum disorder but has not been associated with myelin oligodendrocyte glycoprotein-IgG (MOG-IgG). OBJECTIVE AND METHODS: Case report at an academic medical center. RESULTS: A 32-year-old woman developed severe transverse myelitis (paraplegia) shortly after SLE onset in the post-partum period. Magnetic resonance imaging (MRI) revealed an LETM, cerebrospinal fluid showed marked inflammation, and testing for infections was negative. Serum live-cell-based assay for MOG-IgG was positive but aquaporin-4-IgG was negative. CONCLUSION: In patients with SLE and LETM, MOG-IgG testing should be considered, in addition to AQP4-IgG.

Screening for postpartum hypomania among Chinese women after childbirth.

This study examines the prevalence and risk factors for postpartum hypomania in women after childbirth as well as examining the potential influence of personality traits in relation to experiencing symptoms of postpartum hypomania. A total of 1022 women no later than 1 month post-birth were recruited in Suzhou, China, between March 2017 and December 2018. Hypomanic symptoms were assessed with the Hypomania Checklist-32 (HCL-32), and a total score of 14 or higher was defined as having hypomanic symptoms. We found 43.6% of the women in our sample had hypomanic symptoms. The results of multiple logistic regression showed that rural residence [p = 0.01, odds ratio (OR) = 0.7, 95% confidence interval (CI) = 0.5-0.9], education background (p = 0.005, OR = 0.6, 95% CI = 0.5-0.9), marriage satisfaction (p = 0.048, OR = 0.9, 95% CI =0.8-1.0), Pittsburgh Sleep Quality Index (PSQI) (p = 0.001, OR = 0.9, 95% CI = 0.9-1.0), Eysenck Personality Questionnaire-Extraversion (p < 0.001, OR = 1.2, 95% CI = 1.1-1.2), Eysenck Personality Questionnaire-Lie (p = 0.01, OR = 0.9, 95% CI = 0.9-1.0), and General Anxiety Disorder-7 (p = 0.02, OR = 1.1, 95% CI = 1.0-1.1) were independently associated with exhibiting hypomanic symptoms. The current study provided insights into hypomanic symptoms in Chinese postpartum women. We also found that extraversion and lie personality were significantly associated with an increased risk of hypomanic symptoms in postpartum women. It is urgent to arrange screening for women at risk of developing postpartum hypomania as soon as possible after giving birth and at regular intervals in the first 6 months to prevent the women developing psychological disorders such as depression and bipolar disorder later on.

Postpartum Galactostasis of the Vulva in a Case of Bilateral Lactating Ectopic Breast Tissue.

BACKGROUND: In the general population, the incidence of accessory breast tissue, a congenital malformation, is 1-5%. The most common site is the lower axilla. Detecting such tissue may be problematic, and accessory breasts below the umbilicus are extremely rare. CASE: This report describes the case of a 5-day postpartum 29-year-old woman, G2P2, with painful vulvar swelling 6 cm in diameter. The patient was diagnosed with polymastia in the vulva, without polythelia, with galactostasis due to suturing of a birth laceration covering an excretory duct. The sutures were removed, and the pain decreased. Breastfeeding was continued. CONCLUSION: Ectopic breast tissue is rare but should be taken into consideration in the differential diagnosis of a vulvar mass, especially postpartum in lactating women.

Simultaneous Pulmonary Embolism and Ischemic Stroke in a Patient with Cor Biloculare after Glenn Anastomosis.

BACKGROUND: Cor biloculare, two-chambered heart due to the absence of atrial and ventricular septa, is a rare congenital heart anomaly. For Cor biloculare and other cardiac defects with single ventricle physiology, Glenn anastomosis has been developed as a palliative procedure. Thrombosis secondary to Glenn anastomosis in the patient with Cor biloculare could pose a serious threat to the survival, and has never been reported before. CASE REPORT: We report the case of a 27-year-old patient, with past history of Glenn anastomosis that was performed 7 years ago for the palliation of Cor biloculare. She presented with pulmonary embolism and ischemic stroke simultaneously at 7 days after Cesarean section. Due to her critical status, systemic anticoagulation with low-molecular-weight heparin was started immediately, followed by lifelong warfarin therapy. Pulmonary embolism regressed and neurological symptoms were considerably diminished after the anticoagulation treatment. CONCLUSION: This case illuminates the potential risk of thrombotic events in this patient cohort and demonstrates that anticoagulation therapy is an effective, secure, and appropriate for the management of this disease.