PMC6334360_01
Development of severe VTE, and its disappearance after treatment at patient's fourth pregnancy. (a~c) Contrast CT image taken at the admission day. (a) Coronal plane, large thrombosis exists in inferior vena cava and femoral vein. (b) Transverse plane at the level of trunk of pulmonary artery. (c) Transverse plane at the level of femoral vein. Yellow circle and arrow indicate the location of venous thrombosis. (d, e) Contrast CT image taken at the start of oral administration of edoxaban. (d) Transverse plane at the level of trunk of pulmonary artery. (e) Transverse plane at the level of femoral vein.
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Then, a bilateral peripheral pulmonary embolism and venous thromboembolism from the left femoral vein to the inferior vena cava (renal vein level) were detected (Figures 1(a), 1(b), and 1(c)). After surgery, VTE improved dramatically and finally disappeared (Figures 1(d) and 1(e)).
Clinical course in patient's fifth pregnancy, and flow chart in delivery. (a) Treatment process and change of ATIII activity and APTT value during pregnancy. Y-axis; % (ATIII) and seconds (sec, APTT). (b) Change of the estimated fetal weight (EFW) of fetus. Dot line indicates the line of -1.5SD. (c) Flowchart that we considered at the delivery.
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To keep ATIII value above 70%, we appropriately changed the dose and frequency (Figure 2(a)). To maintain an APTT value of approximately 50 to 60 seconds, we appropriately changed the dose and frequency (Figure 2(a)). Foetal estimated body weight was from -1.5 to -1.0 SD during pregnancy (Figure 2(b)). We discussed with the cardiovascular doctors and paediatricians and planned a delivery as below (also, a flowchart is shown in Figure 2(c)).
Pathological findings of placenta. Macroscopic view and HE staining are shown. Scale is shown in each figure. (a) Macroscopic view; circumferential-like infarction was observed in a portion approximately 4 cm in radius around the umbilical cord. (b) x40 magnification. Necrosis of villi was observed around that site. Black arrows indicate the necrosis of villi. (c) x40 magnification. Necrosis of the amniotic membrane and chorion, and fibrin precipitation was observed. Black arrows indicate the necrosis, and fibrin precipitation.
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Macroscopically, a circumferential-like infarction was observed in a portion approximately 4 cm in radius around the umbilical cord (Figure 3(a)). In addition, necrosis of villi and fibrin precipitation was observed around that site (Figures 3(b) and 3(c)).