Postpartum Embolism; Postpartum Pulmonary Thrombosis

No doubt that pregnancy leads to several changes in a woman’s physiology from day one, but the abnormal exaggeration of the physiological features of pregnancy could be hazardous. A normal pregnancy is associated with a hypercoagulable state due to the hormonal changes during fetus carriage. The aim of this hormonally-achieved hypercoagulability is to avoid blood loss and bleeding during the delivery process.

On the other hand, increased coagulability makes the mother at a higher risk of venous thrombo-embolism. Moreover, the post-partum period (40 days following delivery) is associated with the same risks of pregnancy due to continued hormonal changes and the start of lactation. Plus, other surgical procedures around delivery process modulate this risk, as caesarian section or episiotomy. These procedures in turn increase sepsis risk, extend the in-hospital time and increase recumbency, which is associated with increased venous thrombo-embolism and pulmonary embolism.

Other associated risk factors, which adds on to the total risk, are increased mother age, immobilization, heart and lung diseases, malignancies, hereditary coagulopathies, recurrent miss carriage and previous history of thrombo-embolism.

Venous and pulmonary- thromboembolism is among the most common complications in the post-partum period, together with peripartum sepsis and major bleeding. Clearly, the risk is higher in the developing countries, but still a serious problem in the western countries with high rates of morbidity and mortality. According to the medical reports, the risk is highest during the early post-partum period. This may be due to the added risk of caesarean section and other surgical procedures, preeclampsia and sepsis. Thus, special care during this period should be maximized to avoid thrombo- embolism.

Before delivery, doctors pay special attention to the clinical signs and diagnostic tests, trying to predict those females at increased risk for thrombosis and avoid these complications at the peri and post-partum periods. These diagnostic efforts involve risk scores and charts for early prediction. The recent guide lines used for thrombo-prophylaxis greatly decreased the prevalence of these thrombotic events.

One of the risk scores that had gain a good reputation over the last decade is the Swedish risk assessment guidelines for venous thrombo-embolism and thrombo-prophylaxis around pregnancy and peri and post-partum periods.

After risk assessment, Prophylactic antithrombotic treatment plan will be then started according to the risk stratification done by the previous score in table (1). Mothers with no risk (i.e. usually no or single risk factor) will require no prophylaxis. Intermediate risk mothers (i.e. with 2 risk factors) will require short term for 1-week parenteral anticoagulants as unfractionated Heparin, Low molecular weight heparin (LMWH), Dalteparin and Tinzaparin. For those with high risk, a longer post-partum prophylaxis is need up to 6 weeks, while those with high risk an antepartum prophylaxis is need to avoid miss carriage and post-partum prophylaxis will be recommended for at least 6 weeks.

These prophylactic strategies are important to avoid the occurrence of thrombo-embolism, but in case the above prophylactic therapies are not enough, treatment with full-dose therapy and hospitalization are recommended, followed by a long-term oral anticoagulant as secondary prophylaxis. In other words, it will be treated similar to other traditional venous thrombo-embolic events. Also, in these cases, care should be given to any future pregnancies in mothers with a higher risk or past thrombo-embolic events.