Location
LSU Health Sciences Center - New Orleans
Event Website
https://www.medschool.lsuhsc.edu/genetics/2024_medical_student_research_poster_symposium.aspx
Presentation Date
5-11-2024 11:30 AM
Description
Introduction: Hypercoagulability secondary to pregnancy is an anticipated protective physiological adaptation that reduces the risk of postpartum hemorrhage in the laboring mother. The resulting prothrombotic state typically presents as deep vein thrombosis or pulmonary embolism2 . In this report, we aim to describe the case of a multiparous woman with a rare presentation of portal vein thrombosis (PVT).
Case: A 27-year-old woman (G2P0202) with no previous history of thrombosis or known thrombophilic condition presented to the Emergency Department 26 days postpartum with severe abdominal pain that limited ambulation. The patient’s most recent obstetric course was complicated by preeclampsia and iron deficiency anemia. She had an uncomplicated spontaneous vaginal delivery at 36 weeks gestational age and was discharged with persisting postpartum hypertension. On examination she was febrile, tachycardic, tachypneic, and peritonitic. Computed tomography of the abdomen and pelvis revealed a portal vein thrombus that extended into the proximal splenic vein and diffusely involved the superior mesenteric vein and its branches. An emergent exploratory laparotomy confirmed ischemic small bowel involving the mid jejunum, and 45cm of necrotic tissue was resected. Due to postoperative hematemesis, anticoagulation was held. Interventional radiology performed a suction thrombectomy to restore patency of the portal vein and prevent further ischemia as thrombotic management with anticoagulation was discontinued due to blood loss and increasing transfusion requirements. The patient’s postoperative course was further complicated by anastomotic bleeding at the primary site and large abdominal hematoma formation, both of which were managed conservatively. Additionally, she developed an acute kidney injury secondary to ischemia, pleural effusion, and decompensated heart failure. The patient was discharged with recommendations to continue anticoagulation with rivaroxaban for 30 days. Since, she has followed out-patient with cardiology and primary care for hypertensive management. In discussion of obstetric care, she was advised that future pregnancies would pose significant, life-threatening risks.
Discussion: Portal vein thrombosis is an uncommon manifestation of postpartum hypercoagulability. Other accounts reported of similar cases include women who presented with characteristic abdominal pain concerning for ischemia within the first two weeks postpartum, those whose obstetric course was complicated by cesarean section and resulted in postoperative immobility, and those with hematologic disorders1,3,4,5. This patient presented approximately four weeks postpartum, underwent vaginal delivery, and had a negative thrombophilia workup. In a patient who has already endured extensive ischemic damage, mitigating the risk of further thrombosis was of primary concern. Anticoagulation is the mainstay of treatment for portal vein thrombosis, rather than surgical or percutaneous thrombectomy. However, in this patient with postoperative bleeding, a procedural approach was warranted. This case underscores the importance of thoroughly evaluating abdominal pain in the postpartum period and effectively evaluating thrombotic risk to reduce the occurrence of lifealtering sequelae.
1. Adrados C, Trastour C, Havet J, Chassang M, Bongain A. Orientation diagnostique devant des douleurs abdominales du post-partum: à propos d'un cas rare de thrombose portale [Diagnosis of postpartum abdominal pain: about a rare case of portal vein thrombosis]. Gynecol Obstet Fertil. 2015;43(1):68-70. doi:10.1016/j.gyobfe.2014.07.021
2. Battinelli EM, Marshall A, Connors JM. The role of thrombophilia in pregnancy. Thrombosis. 2013;2013:516420. doi:10.1155/2013/516420
3. Hibi A, Mogi K. Portal vein thrombosis after cesarean section in a patient on prolonged bed rest due to threatened preterm labor. Clin Case Rep. 2018;6(3):531-536. Published 2018 Feb 6. doi:10.1002/ccr3.1405
4. Ntounis T, Zioutos KA, Koutras A, et al. Portal Vein Thrombosis after C-Section in a Patient with Polycythemia Vera (PV) Due to Pregnancy and Iron Deficiency Anemia (IDA). Clin Pract. 2022;12(6):1069-1077. Published 2022 Dec 14. doi:10.3390/clinpract12060109
5. Rousso D, Mamopoulos A, Goulis J, Mandala E, Mavromatidis G. Postpartum mesenteric, splenic and portal vein thrombosis. J Obstet Gynaecol. 2008;28(4):441-443. doi:10.1080/01443610802164250
Recommended Citation
Mott, Karlee, "A Complex Case of Portal Vein Thrombosis in the Postpartum Period" (2024). Medical Student Research Poster Symposium. 80.
https://digitalscholar.lsuhsc.edu/sommrd/2024MSRD/Posters/80
Included in
A Complex Case of Portal Vein Thrombosis in the Postpartum Period
LSU Health Sciences Center - New Orleans
Introduction: Hypercoagulability secondary to pregnancy is an anticipated protective physiological adaptation that reduces the risk of postpartum hemorrhage in the laboring mother. The resulting prothrombotic state typically presents as deep vein thrombosis or pulmonary embolism2 . In this report, we aim to describe the case of a multiparous woman with a rare presentation of portal vein thrombosis (PVT).
Case: A 27-year-old woman (G2P0202) with no previous history of thrombosis or known thrombophilic condition presented to the Emergency Department 26 days postpartum with severe abdominal pain that limited ambulation. The patient’s most recent obstetric course was complicated by preeclampsia and iron deficiency anemia. She had an uncomplicated spontaneous vaginal delivery at 36 weeks gestational age and was discharged with persisting postpartum hypertension. On examination she was febrile, tachycardic, tachypneic, and peritonitic. Computed tomography of the abdomen and pelvis revealed a portal vein thrombus that extended into the proximal splenic vein and diffusely involved the superior mesenteric vein and its branches. An emergent exploratory laparotomy confirmed ischemic small bowel involving the mid jejunum, and 45cm of necrotic tissue was resected. Due to postoperative hematemesis, anticoagulation was held. Interventional radiology performed a suction thrombectomy to restore patency of the portal vein and prevent further ischemia as thrombotic management with anticoagulation was discontinued due to blood loss and increasing transfusion requirements. The patient’s postoperative course was further complicated by anastomotic bleeding at the primary site and large abdominal hematoma formation, both of which were managed conservatively. Additionally, she developed an acute kidney injury secondary to ischemia, pleural effusion, and decompensated heart failure. The patient was discharged with recommendations to continue anticoagulation with rivaroxaban for 30 days. Since, she has followed out-patient with cardiology and primary care for hypertensive management. In discussion of obstetric care, she was advised that future pregnancies would pose significant, life-threatening risks.
Discussion: Portal vein thrombosis is an uncommon manifestation of postpartum hypercoagulability. Other accounts reported of similar cases include women who presented with characteristic abdominal pain concerning for ischemia within the first two weeks postpartum, those whose obstetric course was complicated by cesarean section and resulted in postoperative immobility, and those with hematologic disorders1,3,4,5. This patient presented approximately four weeks postpartum, underwent vaginal delivery, and had a negative thrombophilia workup. In a patient who has already endured extensive ischemic damage, mitigating the risk of further thrombosis was of primary concern. Anticoagulation is the mainstay of treatment for portal vein thrombosis, rather than surgical or percutaneous thrombectomy. However, in this patient with postoperative bleeding, a procedural approach was warranted. This case underscores the importance of thoroughly evaluating abdominal pain in the postpartum period and effectively evaluating thrombotic risk to reduce the occurrence of lifealtering sequelae.
1. Adrados C, Trastour C, Havet J, Chassang M, Bongain A. Orientation diagnostique devant des douleurs abdominales du post-partum: à propos d'un cas rare de thrombose portale [Diagnosis of postpartum abdominal pain: about a rare case of portal vein thrombosis]. Gynecol Obstet Fertil. 2015;43(1):68-70. doi:10.1016/j.gyobfe.2014.07.021
2. Battinelli EM, Marshall A, Connors JM. The role of thrombophilia in pregnancy. Thrombosis. 2013;2013:516420. doi:10.1155/2013/516420
3. Hibi A, Mogi K. Portal vein thrombosis after cesarean section in a patient on prolonged bed rest due to threatened preterm labor. Clin Case Rep. 2018;6(3):531-536. Published 2018 Feb 6. doi:10.1002/ccr3.1405
4. Ntounis T, Zioutos KA, Koutras A, et al. Portal Vein Thrombosis after C-Section in a Patient with Polycythemia Vera (PV) Due to Pregnancy and Iron Deficiency Anemia (IDA). Clin Pract. 2022;12(6):1069-1077. Published 2022 Dec 14. doi:10.3390/clinpract12060109
5. Rousso D, Mamopoulos A, Goulis J, Mandala E, Mavromatidis G. Postpartum mesenteric, splenic and portal vein thrombosis. J Obstet Gynaecol. 2008;28(4):441-443. doi:10.1080/01443610802164250
https://digitalscholar.lsuhsc.edu/sommrd/2024MSRD/Posters/80
Comments
Mentor: Dr. Mo Al Efishat, MD, FACS, FSSO Clinical Assistant Professor of Surgery – LSU