Post-partum sacral fracture associated with heparin treatment

We report the case of a 19-year-old woman who consulted for low-back pain 3 weeks after her first delivery. This young woman had a personal history of protein C deficiency and was treated daily during her pregnancy with low-molecular-weight heparin. Her body mass index was 34 and she only gained 10 kg during her pregnancy. Since the delivery – which occurred without any complication – she had suffered from a gradually increasing right-buttock pain and limp. Magnetic resonance imaging (MRI) revealed a fracture of the right sacral ala. After analgesia and 1 month of home relative bed rest, the patient recovered her functional capacities. Regarding our patient, who had no potential clinical risk factors for osteoporosis, the causal effect of heparin is thus possible but not certain. This case report illustrates the fact that clinicians should have a high suspicion of pelvic fracture in post-partum women, even in very young ones, presenting sudden onset of low back and pelvic pain, especially when they have received heparin during pregnancy. MRI seems to be the key exam because it is able to detect and stage fractures or microfractures.     

Transitory bone marrow oedema of the hip in pregnant patient with antiphospholipid syndrome: A case report

BackgroundTransient bone marrow oedema (BMO) of the hip presents with pain, is diagnosed by magnetic resonance imaging (MRI), and usually resolves within 6 months. Risk factors include pregnancy. Avascular necrosis of bone and an association with BMO are among the less common presentations of antiphospholipid syndrome (APS).Aim of the workTo present a young Croatian female APS patient who developed transient BMO during pregnancy which spontaneously resolved postpartum.Case reportAfter developing left leg deep vein thrombosis and positive lupus anticoagulant at 22 years old, the patient was diagnosed with primary APS. Antinuclear antibody was borderline, but classification criteria for SLE were not fulfilled. She had an early missed abortion during her first pregnancy while receiving low-weight molecular heparin (LWMH) (enoxaparin 40 mg), and her second pregnancy was to term with LWMH, aspirin, and hydroxychloroquine 200 mg daily. During the third trimester of this pregnancy, she developed excruciating bilateral hip pain to the point she could barely walk. Based on an MRI scan, the patient was diagnosed with bilateral BMO of the femoral head. The condition improved and resolved within four months with conservative treatment postpartum, as confirmed by followup MRI.ConclusionConsidering that pregnancy and APS are risk factors for BMO, both played a role in the development of BMO and the severity of presentation. This case report presents a differential diagnosis of hip pain in pregnant patients, especially with APS. Although APS is commonly associated with AVN, it may also be associated with transient BMO.     

Sudden death due to bilateral pulmonary thromboembolism in a patient with multiple myeloma: an autopsy case report]

We encountered a patient with multiple myeloma who died suddenly, in whom bilateral pulmonary artery thrombosis was found at autopsy. The patient was a 50-year-old woman who had received chemotherapy for multiple myeloma at a local clinic for 4 years, and was transferred to our hospital because of recurrence of multiple myeloma in August 1990. Despite chemotherapy performed after admission, serum globulin level increased and her low back pain worsened, and she was generally restricted to bed. On October 21, she developed sudden dyspnea, became markedly cyanotic, lost consciousness, and then suffered a cardiopulmonary arrest. Autopsy revealed bilateral pulmonary artery thrombosis as well as thrombosis in the pelvic veins. Hyperviscosity due to multiple myeloma and long-term recumbency were the probable causes of pelvic venous thrombosis and subsequent pulmonary artery thrombosis. We report a rare case of bilateral pulmonary artery thrombosis which developed during the course of multiple myeloma and led to sudden death.     

Prise en charge de l’acromégalie évolutive au cours de la grossesse

Pregnancy in acromegalic patients is an infrequent event, due to perturbed gonadotroph function. On the other hand, pregnancy may cause an enlargement of the adenoma or an increase of growth hormone (GH) secretion. We report the case of a 26-year-old woman with a GH-secreting pituitary macroadenoma who was operated by transphenoidal approach. After surgery, she had a persistant acromegaly due to an intrasellar tumour. She was treated by lanreotide. After one year, the patient had married and became pregnant. Lanreotide was stopped when the diagnosis of pregnancy was established. The follow-up of this patient showed a progressive increase of IGF1 level during pregnancy without tumoral syndrome or visual troubles. No metabolic complication was detected. The patient went to term and gave birth to a healthy baby. In postpartum, the IGF1 level was normal, but the brain MRI revealed a 10 mm intrasellar tumour. The pituitary adenoma was not significantly enlarged during pregnancy. Therefore, pregnancy doesn’t influence acromegaly in young women well controlled by medical treatment.     

Ulcerative colitis case beginning during pregnancy in a patient with antiphospholipid antibody syndrome.

It is well known that there may be an increased tendency for thrombosis in inflammatory bowel disease (IBD). This study presents a case with antiphospholipid antibody syndrome with ulcerative colitis diagnosed during pregnancy. A 30-year-old female patient, in her 6th week of pregnancy, applied to our clinic with complaints of abdominal pain and bloody diarrhea. She had a history of three abortions. She had been given aspirin and heparin treatment due to high levels of anticardiolipin antibody (ACA) in previous examinations that led to the diagnosis of antiphospholipid antibody syndrome. As the left colonoscopic examination of the patient showed ulcerative colitis, aspirin treatment was replaced with mesalazine (750 mg/day, in 3 equal doses). There was a significant relief in complaints of the patient. Medical treatment was interrupted three days before delivery. The patient delivered a baby, at full-term, of 3.6 kg by cesarean section. No adverse effects were observed in the mother or the baby due to the medical treatment. After delivery, mesalazine treatment was restarted. This case is interesting due to the co-diagnosis of IBD in a pregnant woman with antiphospholipid antibody syndrome. Successful and uncomplicated treatment of the patient with mesalazine should also be noted.     

Warfarin treatment during pregnancy: a clinical note.

The case history is presented of a woman aged 38 who received warfarin treatment because of a mitral valve replacement. During the first trimester of pregnancy, her prothrombin time was 20% of normal and kept at 40% until the 38th week of gestation. Then the patient received heparin until a few days after delivery of a normal child.     

Anticoagulation in pregnant women after artificial heart valve replacement: is low-molecular-weight heparin an alternative?

We report on the case of a 24-year-old pregnant woman with acute mechanical mitral valve thrombosis due to a treatment failure of low molecular weight heparin (LMWH) for permanent anticoagulation following mechanical valve replacement. Initially, our patient was put on oral warfarin for anticoagulation, but when her pregnancy was perceived the anticoagulation regimen was switched to daily subcutaneous administration of LMWH in order to minimize the risk of warfarin-induced embryopathy. During her 24th week of gestation she developed acute life-threatening pulmonary edema and hemodynamic instability, which was caused by an acute thrombosis of her artificial mitral valve. In an emergency operation the thrombozed valve was replaced by a porcine biological heart valve. The patient recovered uneventfully and gave birth to a healthy child in her 35th gestational week by cesarean section. In addition we discuss the rationale of different anticoagulation regimens with regard to maternal and fetal outcome with special consideration of LMWH as an alternative strategy to oral anticoagulation during pregnancy in women with mechanical heart valves.     

Thyroid-stimulating antibodies and thyroid stimulation-blocking antibodies during the pregnancy and postpartum period: a case report.

This report describes a unique pattern of changes in thyroid function and thyroid antibodies in a woman during the course of two pregnancies and two postpartum periods. A 25-year-old woman developed hypothyroidism in the postpartum period after the delivery of her first child. She was found to have potent thyroid stimulation-blocking antibodies (TSBAb) in the serum. One year later, she became pregnant again, and during the pregnancy, TSBAb had decreased to an undetectable level. She gave birth to the second healthy child and developed postpartum thyrotoxicosis, probably due to destruction of the thyroid gland, which gradually resolved. In this postpartum period, serum TSBAb levels increased. Eight months postpartum, she developed what appeared to be Graves' disease with an elevated 123I-thyroid uptake. Serum thyroid-stimulating antibodies (TSAb) were found at that time, and the TSBAb had disappeared from her serum.     

Deciduosis of the Appendix During Pregnancy

Acute appendicitis is an important differential diagnosis in patients with right lower quadrant pain during pregnancy. Endometriosis, a hormone-related pathology, is another possibility. Patients with endometriosis are typically symptomatic before pregnancy. Stromal endometriosis is a variant of endometriosis that presents no symptoms before pregnancy but which occasionally presents with the new onset of symptoms during pregnancy. We report the case of a 35-year-old woman in her 8th month of pregnancy who presented with impending appendiceal rupture due to deciduosis of the appendix, a progesterone-related condition, during pregnancy. This case suggests that deciduosis/stromal endometriosis should be considered as a differential diagnosis of acute abdomen during pregnancy, even if the patient is asymptomatic before pregnancy.     

Two successful pregnancies in a woman with chronic thrombotic thrombocytopenic purpura treated by plasma infusion

A 21-year-old primigravida in her 20th week of pregnancy developed TTP. She was managed with weekly or semiweekly plasma infusions and delivered a healthy 1.6 kg baby 2 weeks prior to the expected date of delivery. After delivery she continued to have active TTP with thrombocytopenia which responded repeatedly to plasma infusion though their frequency gradually decreased to about one unit every 3-4 weeks. Three years after the birth of the first child she conceived again and was easily managed with repeated plasma infusions although the frequency and amount of plasma required to prevent thrombocytopenia were increased. She delivered a normal 3.4 kg term baby after which she again had a decreased plasma requirement. This is the first report of a woman with 5 years of active TTP managed with plasma alone. She experienced two pregnancies in which both mother and infant survived. We believe that the use of plasma in the management of TTP during pregnancy will improve the survival rate of both mother and infant. At the time of second birth, the platelet count was low in the mother but normal in the baby. This suggests that the platelet depressing factor of this patient does not cross the placental barrier.     

New onset ventricular tachycardia during pregnancy.

A previously healthy young woman who developed the new onset of symptomatic sustained ventricular tachycardia during pregnancy is described. Evaluation revealed mitral valve prolapse with minimal mitral regurgitation, and normal left ventricular size and function. The arrhythmia resolved after delivery, but recurred nine months later in a nonsustained form. Electrophysiologic study revealed only nonsustained ventricular tachycardia, and she was treated with propafenone. It is suggested that the pregnant state may have been important in the pathogenesis of her arrhythmia.     

Learning on the Web. Case 9: a mother's heartache

A 35 year old white woman presented with chest pain and breathlessness 10 days following an elective caesarean section. This was her second pregnancy, which had proceeded to term without complications. Up until then, she had been completely fit and well. Her ECGs were found to be abnormal, and the ultrasound study of her heart gave serious cause for concern. This interactive case report charts the evolution of the patient's clinical course and provides concise and up-to-date literature reviews on two cardiac conditions that share a predilection for women in the peripartum period.     

Menorrhagia due to a qualitative deficiency of plasminogen activator inhibitor-1: case report and literature review.

A case is presented of a 26-year-old woman who was referred to the hematology clinic because of her report of a family history of plasminogen activator inhibitor-1 (PAI-1) deficiency. Since menarche, she had suffered from severe menorrhagia, but she had assumed that this was unrelated to her mother's history of repeated life-threatening bleeding. Her menorraghia was evident by using greater than 100 pads per period, bleeding as long as 4 continuous months, and even bleeding through her clothes despite using both tampons and pads. Evaluation with pelvic examination, endometrial biopsy, and pelvic ultrasound was unremarkable. Medroxyprogesterone acetate treatment for her dysfunctional uterine bleeding was unsuccessful. Laboratory evaluation revealed iron deficiency anemia but otherwise normal platelets, bleeding time, prothrombin time, activated partial thromboplastin time, and vonWillebrand's studies. Despite any preconceptions, examination for a fibrinolytic defect ultimately demonstrated a PAI-1 antigen level of 11.4 ng/mL (4.0-43 ng/mL) and PAI-1 activity less than 5 AU/mL (5-37 AU/mL) and clinically supported a diagnosis of a hereditary, qualitative PAI-1 defect. She was treated with aminocaproic acid with return to relatively normal menses. Future treatment should also prevent excessive bleeding during trauma, surgery, or childbirth. Further evaluation of this patient and her family is planned and may help elucidate the important role of PAI-1 in the complicated balance between hemostasis and hemorrhage.     

Successful treatment of a patient with primary Sjögren's syndrome complicated with pericarditis during pregnancy

A 35-year-old woman with primary Sj?gren's syndrome (pSS) developed fever and chest pain during pregnancy. When the dose of prednisolone was reduced, she experienced chest pain with elevated CRP and D-dimer, resulting in admission to our hospital with marked cardiomegaly and pleural effusion. Because there was no evidence of other autoimmune disorders or infection, oral prednisolone was increased to 30 mg daily with heparin, and hypercoagulopathy was carefully monitored. The patient's condition improved rapidly, and she delivered a healthy baby. This is the first case to support the beneficial effect of prednisolone in pericarditis with pSS, and illustrates its safety during pregnancy.     

Chronic pelvic girdle relaxation

A 24-year-old pregnant woman presented with severe pain in her symphysis pubis and right buttock. The iliac gapping test evoked pain in the right sacroiliac joint and symphysis pubis. The iliac compression test evoked pain in the symphysis pubis. The Patric test evoked pain in the symphysis pubis and right sacroiliac joint. Radiographs of the pelvis showed no abnormality except for a 7 mm separation of the symphysis pubis and mild bilateral acetabular dysplasia. Four and a half years later and 12 weeks into her next pregnancy she again complained of moderate pain in the symphysis pubis. Computed tomography, magnetic resonance imaging and bone scintigraphy using^99mTc MDP showed no abnormality in the pelvis and spine. Laboratory data were normal. An injection of steroid and lidocaine into the right sacroiliac joint dramatically improved the pain. Eight years after first delivery she could walk independently, but often complained of mild to severe pelvic pain which was relieved with non-steroidal anti-inflammatory drugs.     

Fondaparinux as anticoagulant in a pregnant woman with heparin allergy.

We report a patient who had a history of deep vein thrombosis in a previous pregnancy. She was treated with heparins without any reactions in the index pregnancy. Subsequently, when the patient became pregnant again, she developed an acute cutaneous reaction to the low molecular heparin enoxaparin 3 weeks after initiation of therapy. She developed a similar reaction to delteparin as well. She was therefore treated with warfarin until 36 weeks of gestation. Then she was treated with fondaparinux (Arixtra, Sanofi-Synthelabo, Paris, France) 2.5 mg daily for the remainder of the pregnancy. Delivery was at term by induction of labour. Fondaparinux was stopped on the day of the induction of labour. It was re-started 6 h post-delivery and the patient was anticoagulated with warfarin in the post-partum period. There were no bleeding tendencies or recurrences of thrombosis during fondaparinux therapy. Both mother and baby were well after delivery.     

Management with antithrombin III concentrate in a pregnant woman with hereditary antithrombin III deficiency

Pregnant women with hereditary antithrombin III (AT-III) deficiency are frequently associated with thromboembolic disorders. We have treated a pregnant woman with hereditary AT-III deficiency, who had suffered from thromboembolic disorders at her past three gestations, with AT-III concentrate. Dosage of AT-III concentrate to maintain plasma AT-III activity over 80% was 3,500 units per week during second and third trimesters, but more frequent administration was necessary around delivery. In recent reports, pregnant women with hereditary AT-III deficiency had been treated with heparin or warfarin except for during abortion and delivery, in which time AT-III concentrate was widely utilized. But the use of heparin or warfarin during gestation is occasionally harmful, AT-III concentrate should be chosen for management in pregnancy in women with hereditary AT-III deficiency.     

A case report: pregnancy-induced severe osteoporosis with eight vertebral fractures

Osteoporosis associated with pregnancy and lactation is a rare condition. The prevalence, etiology and its pathogenesis is unknown. It causes one or more vertebral fractures with severe, prolonged back pain and height loss in affected women. Majority of the cases are seen in the third trimester or just after delivery in primagravid women. In this case report, a 30-year-old woman who had severe pregnancy-induced osteoporosis with 8 vertebral fractures was presented. During last month of her first pregnancy she had moderate back pain. After delivery, the back pain has gotten worse. The radiological examinations have shown that there was 50% in T₆, T₈ and T₁₀; 30% in L₂; 20% in L₁ height loss and biconcave vertebral images in L_3–5. In the bone mineral density, L_2–4 T score was −4.7 and total femoral T score was −3.1. There was no abnormality in the laboratory findings except mild elevation in alkaline phosphates. Although pregnancy-associated osteoporosis is a rare condition, when pain occurs in the last trimester or early postpartum period, it should be considered in differential diagnosis.     

The successful use of protein C concentrate during pregnancy in a patient with type 1 protein C deficiency, previous thrombosis and recurrent fetal loss

The risks of venous thrombosis and fetal loss are increased in patients with protein C deficiency. We describe a patient with a history of thrombosis and recurrent fetal loss who was found to have type 1 protein C deficiency. In view of her history and intolerance of heparin preparations, she was treated with protein C concentrate during the first and third trimesters of her seventh pregnancy. The patient suffered no thromboembolic event during this pregnancy and gave birth to a healthy infant. The implications of the success of this therapeutic strategy are discussed.     

Successful treatment of an acute flare of steroid-resistant Crohn's colitis during pregnancy with unfractionated heparin

Recent reports suggest that unfractionated heparin may be a useful adjunct in the treatment of inflammatory bowel disease (IBD). We report the successful use of subcutaneous unfractionated heparin to treat a moderate-to-severe flare of Crohn's disease during pregnancy, which was refractory to standard therapy. The patient received 10,000 units of unfractionated heparin subcutaneously twice a day after her Crohn's colitis failed to come under remission with intravenous corticosteroids. Heparin was continued throughout her pregnancy. Following initiation of adjunctive heparin therapy, the patient experienced a rapid clinical response, was able to discontinue intravenous steroids, discharge from the hospital, and ultimately deliver a healthy term newborn. Although there is extensive obstetric experience with heparin in the treatment of thrombosis associated with pregnancy, there is limited information regarding its use in IBD patients during pregnancy. Because heparin has an established track record in maternal-fetal medicine, this agent may be considered in women who suffer an inflammatory flare of IBD during pregnancy who have not responded to standard treatment.