Age-related disparities in complications among women with peripartum cardiomyopathy.

INTRODUCTION: While the exact pathogenesis of peripartum cardiomyopathy, a potentially life-threatening condition, is still unknown, its incidence is rising globally. We sought to understand the differences in outcomes and complications based on age. METHODS: Records from the 2016-2020 National Inpatient Sample were used for our study. The sample consisted of females diagnosed with peripartum cardiomyopathy that required hospitalization care. They were divided into two age-based cohorts: 15-29 years and 30-40 years. We evaluated differences in in-hospital complications between the two groups using multivariable regression. RESULTS: The analysis consisted of 20520 females diagnosed with peripartum cardiomyopathy, of whom 57.3 % were in the 30-40 years cohort and 42.7 % in the 15-29 years group. The prevalence of cardiovascular risk factors such as smoking, obesity, hypertension, diabetes and lipid disorder was higher among women aged 30-40 years (p < 0.01). These patients also demonstrated higher odds of reporting acute ischemic stroke (aOR 1.354, 95 % CI 1.038-1.767, p = 0.026) while having a reduced risk of cardiogenic shock (aOR 0.787, 95 % CI 0.688-0.901, p < 0.01) as compared to those aged 15-29 years during their hospitalisation with PPCM. No statistically significant differences were noted for events of acute kidney injury (aOR 1.074, 95 % CI 0.976-1.182, p = 0.143), acute pulmonary oedema (aOR 1.147, 95 % CI 0.988-1.332, p = 0.071) or in-hospital mortality (aOR 0.978, 95 % CI 0.742-1.290, p = 0.877). CONCLUSION: Peripartum cardiomyopathy is a serious condition that requires appropriate care and management. Our study linked cases of ages 30-40 years with increased odds of acute ischemic stroke but lower odds of cardiogenic shock.

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.

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.

Placental site trophoblastic tumour: five challenges of patient clinical management.

Placental site trophoblastic tumour is a rare form of gestational trophoblastic disease accounting for about 1%-2% of all trophoblastic tumours. Diagnosis and management of placental site trophoblastic tumour can be difficult.We report a case of a 30-year-old woman diagnosed with a placental site trophoblastic tumour and identify the challenges in diagnosis and treatment of this rare situation. The presenting sign was abnormal vaginal bleeding that started 3 months after delivery. Image exams revealed an enlarged uterus with a heterogeneous mass, with vesicular pattern, and the increased vascularisation serum human chorionic gonadotropin level was above normal range. The histological diagnosis was achieved through hysteroscopic biopsy. Staging exams revealed pulmonary micronodules. The patient was successfully treated with hysterectomy and chemotherapy. The latest follow-up (37 months after diagnosis) was uneventful, and the patient exhibited no signs of recurrence or metastasis.

Prevalence and Treatment of Postpartum Stress Urinary Incontinence: A Systematic Review.

OBJECTIVES: Many women present for treatment of stress urinary incontinence (SUI) after childbirth. This systematic review describes the efficacy of treatment options for SUI initiated during the 12 months after delivery. METHODS: We conducted a systematic review to identify studies comparing treatment options for SUI initiated in the 12 months after parturition. We searched MEDLINE from inception to February 2019, using Medical Subject Heading terms related to pregnancy and urinary incontinence. Preintervention and postintervention populations were compared using analysis of variance with Fisher least significant difference method used to determine efficacy between groups. Grades for Recommendation, Assessment, Development and Evaluation system was used to categorize quality of evidence as high, moderate, low, or very low. RESULTS: We double screened 4548 abstracts, identifying 98 articles for full-text review. Seven studies met the eligibility criteria and were included. Compared with a control group, the 4 interventions identified outperformed the control group (P < 0.001) using Fisher (with effect sizes noted): (1) supervised pelvic floor physical therapy (0.76), (2) electrical stimulation (0.77), (3) home physical therapy (PT) (0.44), and (4) surgery (not applicable). Based on Grades for Recommendation, Assessment, Development and Evaluation assessment, there was moderate evidence to support PT and electrical stimulation, with insufficient evidence for surgery. There were no significant differences in parity, age, or body mass index via analysis of variance. The overall strength of evidence is poor for the treatment of postpartum SUI; more data are needed to fully evaluate other treatment options. CONCLUSIONS: All identified interventions demonstrated greater improvement for postpartum SUI over no treatment. Supervised PT ± electrostimulation was the most effective nonsurgical intervention.

Clinical Features and Outcomes of Pregnancy-Related Acute Aortic Dissection.

Importance: Women with aortopathy conditions are at risk for pregnancy-related aortic dissection, and these conditions may not be recognized until after the aortic dissection occurs. Objective: To examine the clinical characteristics, imaging features, and outcomes in women with pregnancy-related acute aortic dissection. Design, Setting, and Participants: A cohort study, comprising data from the International Registry of Acute Aortic Dissection (IRAD) (February 1, 1998, to February 28, 2018). The multicenter referral center study included 29 women with aortic dissection during pregnancy or less than 12 weeks post partum in IRAD from 1998 to 2018. Main Outcomes and Measures: Clinical features of pregnancy-related aortic dissection to be studied included underlying aortopathy, aortic size, type of aortic dissection, timing of dissection, hypertension, and previous aortic surgery. Results: A total of 29 women (mean [SD] age, 32 [6] years) had pregnancy-related aortic dissection, representing 0.3% of all aortic dissections and 1% of aortic dissection in women in the IRAD. Among women younger than 35 years, aortic dissection was related to pregnancy in 20 of 105 women (19%). Thirteen women (45%) had type A aortic dissection, and 16 women (55%) had type B. Aortic dissection onset was known in 27 women (93%): 15 during pregnancy, 4 in the first trimester, and 11 in the third trimester; 12 were post partum, occurring a mean (SD) of 12.5 (14) days post partum. At type A aortic dissection diagnosis, the mean (SD) aortic diameters were sinus of Valsalva, 54.5 (5) mm and ascending aorta, 54.7 (6) mm. At type B aortic dissection diagnosis, the mean (SD) descending aortic diameter was 32.5 (5) mm. Twenty women (69%) had an aortopathy condition or a positive family history: 13 women (65%) with Marfan syndrome, 2 women (10%) with Loeys-Dietz syndrome, 2 women (10%) with bicuspid aortic valves, 2 women (10%) with a family history of aortic disease, and 1 woman (5%) with familial thoracic aortic aneurysm. Aortopathy was not recognized until after aortic dissection in 47% of the women. Twenty-eight women (97%) survived aortic dissection hospitalization. Conclusions and Relevance: Aortic dissection complicating pregnancy is rare. Most pregnancy-related aortic dissection is due to an aortopathy often not diagnosed until after aortic dissection. In this study, type A aortic dissections were associated with a dilated aorta, and type B aortic dissections often were not. Recognition of underlying conditions and risks for aortic dissection may improve management of pregnancy in women with aortopathy.

Idiopathic Subglottic Stenosis during Pregnancy: A Support Group Survey.

OBJECTIVES: (1) To determine how pregnancy affects idiopathic subglottic stenosis (iSGS) symptoms. (2) To determine treatments utilized (including operating room (OR) and in-office procedures) for iSGS before, during, and after pregnancy. METHODS: A 24-question survey was distributed to an international iSGS support group to assess the patient experience among individuals who have been pregnant with diagnosis of iSGS. Descriptive statistics and chi2 analyses were completed. RESULTS: A total of 413 iSGS patients participated; 84.7% (n = 350) of patients were diagnosed prior to menopause. A total of 25.5% patients reported being pregnant when they had airway stenosis; 71.1% of those reported more severe airway symptoms during pregnancy. The proportion of patients that reported requiring ≥1 OR interventions (microlaryngoscopy and bronchoscopy, laser, balloon dilation, or steroid injection) before, during and after pregnancy was the following, respectively: 37.3%, 35.6%, 51.3%. Whereas the proportion of patients that reported requiring ≥1 in-office interventions (awake balloon dilation or steroid injection) before, during and after pregnancy was the following, respectively: 13.6%, 11.8%, 15.8%. Number of pregnancies and age of diagnosis was not related to severity of symptoms or requiring more airway interventions (P > .05). CONCLUSIONS: This survey reveals worsening of symptoms during pregnancy, however, this did not lead to increase in operative or clinic interventions to improve airway symptoms during pregnancy. Future avenues for research include optimizing management of airway symptoms during pregnancy to limit OR-based interventions. LEVEL OF EVIDENCE: Level IV.

Myeloproliferative neoplasms and pregnancy: Overview and practice recommendations.

Pregnancy in the context of myeloproliferative neoplasms (MPN) poses unique fetal and maternal challenges. Current literature in this regard mostly involves essential thrombocythemia (ET) and less so polycythemia vera (PV) or myelofibrosis. In ET, live birth rate is estimated at 70% with first trimester fetal loss (˜ 30%) as the major complication. Risk of pregnancy-associated complications is higher in PV, thus mandating a more aggressive treatment approach. Herein, we appraise the relevant literature, share our own experience and propose management recommendations. Aspirin therapy may offer protection against fetal loss; however the additive benefit of systemic anticoagulation or cytoreductive therapy, in the absence of high risk disease, is unclear. We recommend cytoreductive therapy in the form of interferon alpha in all high risk and select low-risk ET and PV patients with history of recurrent fetal loss, prominent splenomegaly or suboptimal hematocrit control with phlebotomy. In addition, all women with PV should maintain strict hematocrit control <45% with the aid of phlebotomy. Systemic anticoagulation with low molecular weight heparin is advised in patients with history of venous thrombosis. Further clarification awaits prospective clinical trials that implement risk adapted therapeutic interventions.

Managing migraine in pregnancy and breastfeeding.

The disproportionate prevalence of migraine among women in their reproductive years underscores the clinical significance of migraine during pregnancy. This paper discusses how migraine evolves during pregnancy, secondary headache disorders presenting in pregnancy and puerperium, and acute and preventive options for migraine management during pregnancy and lactation. Migraine is influenced by rising estrogen levels during pregnancy and their sharp decline in puerperium. Migraine, and migraine aura, can present for the first time during pregnancy and puerperium. There is also a higher risk for the development of preeclampsia and cerebrovascular headache during these periods. New or refractory headache, hypertension, and abnormal neurological signs are important "red flags" to consider. This paper reviews the diagnostic utility of neuroimaging studies and the risks of each during pregnancy. Untreated migraine can itself lead to preterm delivery, preeclampsia, and low birth weight infants. Behavioral interventions and lifestyle modifications are the cornerstone for migraine treatment during pregnancy. In addition, one should consider the risks and efficacy of each treatment during pregnancy on an individual basis. The protective nature of breastfeeding for migraine is debated, but there is no evidence to suggest breastfeeding worsens migraine. Acute and preventive migraine treatment options are available for nursing mothers. Neuromodulation and neurostimulation devices are additional options for treatment during pregnancy and lactation, while the safety of using calcitonin gene-related peptide receptor antagonists during these times remains to be determined.

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.

Association of Immediate Postpartum Etonogestrel Implant Insertion and Venous Thromboembolism.

OBJECTIVE: To estimate the rate of readmissions for postpartum venous thromboembolism (VTE) during the first 30 days postdelivery between women with and without the immediate postpartum insertion of the etonogestrel contraceptive implant. METHODS: The Nationwide Readmissions Database from 2016 was used to identify women with a singleton delivery, immediate postpartum insertion of the etonogestrel contraceptive implant, and readmission for VTE within 30 days of discharge. Those with a prior history of VTE or anticoagulant therapy were excluded. These women were compared with the number of women readmitted within 30 days for VTE who did not have the contraceptive implant placed during delivery admission. RESULTS: Of 3,387,120 deliveries, 8,369 women underwent etonogestrel contraceptive implant placement during the delivery admission. There was no difference identified in the rate of readmission for VTE between exposed and unexposed women. Of these, seven had received a postpartum etonogestrel contraceptive implant (0.85/1,000; 95% CI 0.22-1.45/1,000 deliveries), compared with 1,192 without an etonogestrel contraceptive implant (0.35/1,000; 95% CI 0.33-0.37/1,000 deliveries); odds ratio (OR) 2.41; 95% CI 0.58-9.89. The rates of diabetes, thrombophilia, systemic lupus erythematosus, and cesarean birth did not differ between groups. Women who underwent etonogestrel contraceptive implant placement were younger and were more likely to have government-sponsored health insurance, a smoking history, hypertension, peripartum infection, or postpartum hemorrhage than women who did not receive an etonogestrel contraceptive implant (P<.001). After adjusting for these confounders, there remained no difference in rates of VTE, adjusted OR 1.81; 95% CI 0.44-7.45. CONCLUSION: The immediate postpartum placement of the etonogestrel contraceptive implant was not associated with an increased rate of VTE; however, our sample size was underpowered to determine no difference.

[Thyroiditis: What's new in 2019?] / Thyroïdites : où en est-on en 2019 ?

Thyroiditis is a frequent and mostly benign disease that can sometimes disrupt the thyroid balance. Their diagnosis, as well as their aetiology, is a necessary step in the management of the patients. Painful thyroiditis includes acute thyroiditis of infectious origin and subacute thyroiditis. The first one can be treated by antibiotics or antifungals depending on the germ found. The second one will be treated with non-steroidal anti-inflammatory drugs or corticosteroids. In cases of Hashimoto's thyroiditis with overt hypothyroidism, replacement therapy with L-thyroxine will be adapted to the TSH level. As amiodarone treatment provides dysthyroidism, the thyroid status should be monitored regularly. Hypothyroidism will be treated using thyroid replacement therapy. Hyperthyroidism imposes a stop of amiodarone when it is possible. Treatment with synthetic antithyroid drugs (propyl-thio-uracil) or corticosteroids could be used whether there is an underlying thyroid disease or not. Immunotherapies with anti-PD-1/PDL1 or anti-CTLA-4 can also provide dysthyroidism. A monitoring of the thyroid assessment needs to be done in these patients, even if there are no clinical signs, which are not very specific in this context. The treatment of hypothyroidism will be based on thyroid replacement therapy according to the TSH level and the presence or absence of anti-TPO antibodies. Treatment of symptomatic hyperthyroidism may involve a prescription of beta-blockers, or synthetic antithyroid drugs in case of positive anti-TSH receptor antibodies. In all cases, it is desirable to contact an endocrinologist to confirm the diagnosis hypothesis and to decide on a suitable treatment.

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.

Cardiomyopathy and pregnancy.

Cardiomyopathy is a group of disorders in which the heart muscle is structurally and functionally abnormal in the absence of other diseases that could cause observed myocardial abnormality. The most common cardiomyopathies are hypertrophic and dilated cardiomyopathy. Rare types are arrhythmogenic right ventricular, restrictive, Takotsubo and left ventricular non-compaction cardiomyopathies. This review of cardiomyopathies in pregnancy shows that peripartum cardiomyopathy is the most common cardiomyopathy in pregnancy. Peripartum cardiomyopathy develops most frequently in the month before or after partum, whereas dilated cardiomyopathy often is known already or develops in the second trimester. Mortality in peripartum cardiomyopathy varies from <2% to 50%. Few reports on dilated cardiomyopathy and pregnancy exist, with only a limited number of patients. Ventricular arrhythmias, heart failure, stroke and death are found in 39%-60% of high-risk patients. However, patients with modest left ventricular dysfunction and good functional class tolerated pregnancy well. Previous studies on >700 pregnancies in 500 women with hypertrophic cardiomyopathy showed that prognosis was generally good, even though three deaths were reported in high-risk patients. Complications include different types of supraventricular and ventricular arrhythmias, heart failure and ischaemic stroke. Recent studies on 200 pregnancies in 100 women with arrhythmogenic right ventricular cardiomyopathy have reported symptoms, including heart failure in 18%-33% of pregnancies. Ventricular tachycardia was found in 0%-33% of patients and syncope in one patient. Information on rare cardiomyopathies is sparse and only presented in case reports. Close monitoring by multidisciplinary teams in referral centres that counsel patients before conception and follow them throughout gestation is recommended.

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.

Repeated Intracranial Hemorrhage After Delivery Induced by Coagulopathy Associated with Multiple Venous Malformations.

BACKGROUND: Venous malformations are classified as slow-flow vascular malformations. Coagulation abnormalities are known to be frequent among patients with venous malformations. We report a case of repeated intracranial hemorrhage after delivery, induced by coagulopathy associated with multiple venous malformations. CASE DESCRIPTION: A 28-year-old woman presented with left chronic subdural hematoma 1 month after successfully giving birth. She had a history of multiple venous malformations around the pubic region and hips. The hematoma was evacuated by burr hole surgery. Three hours later, her level of consciousness rapidly deteriorated and computed tomography showed acute epidural hematoma. The hematoma was removed immediately by craniotomy under general anesthesia. No bleeding points were apparent in the operative field. Continuous bleeding around the dura mater and subdural space were encountered, and hemostasis was not achieved by electrocoagulation. After using fresh frozen plasma, hemostasis was achieved. Level of consciousness and neurologic symptoms improved postoperatively. Magnetic resonance imaging revealed multiple venous malformations in bilateral lower extremities and the pelvis. Disseminated intravascular coagulopathy was diagnosed, and thrombomodulin and blood coagulation factor XIII were administered. She was discharged home without any neurologic deficits. CONCLUSIONS: The delivery activated localized intravascular coagulopathy in the venous malformations and induced chronic subdural hematoma. Surgical interventions then resulted in progression of the coagulopathy to disseminated intravascular coagulopathy, inducing acute epidural hematoma.