|Year : 2013 | Volume
| Issue : 1 | Page : 47-49
Mesenteric venous thrombosis following vaginal delivery
Roopa Sachidananda, Rohini V Bhat Pai, Raghavendra P Rao
Department of Anesthesiology, SDM College of Medical Sciences and Hospital, Dharwad, Karnataka, India
|Date of Web Publication||1-Jul-2013|
Department of Anesthesiology, SDM College of Medical Sciences and Hospital, Dharwad, Karnataka-580009
Source of Support: None, Conflict of Interest: None
Acute abdomen following an uneventful vaginal delivery is a rare occurrence. Diagnosis may be delayed due to pregnancy related comorbid conditions such as preeclampsia, hemolysis elevated, liver enzymes, low platelet (HELLP) count syndrome, acute fatty liver of pregnancy (AFLP), etc. We describe a 21-year-old woman with pre-eclampsia, HELLP syndrome and AFLP with acute abdomen that was managed successfully in our intensive care unit.
Keywords: Acute fatty liver of pregnancy, HELLP syndrome, pre-eclampsia, pregnancy
|How to cite this article:|
Sachidananda R, Bhat Pai RV, Rao RP. Mesenteric venous thrombosis following vaginal delivery. J Obstet Anaesth Crit Care 2013;3:47-9
|How to cite this URL:|
Sachidananda R, Bhat Pai RV, Rao RP. Mesenteric venous thrombosis following vaginal delivery. J Obstet Anaesth Crit Care [serial online] 2013 [cited 2020 Feb 20];3:47-9. Available from: http://www.joacc.com/text.asp?2013/3/1/47/114296
| Introduction|| |
Acute abdomen following an uneventful vaginal delivery is a rare occurrence. Various causes for severe acute postpartum abdominal pain include, pelvic infection, thrombophlebitis, ovarian venous thrombosis, acute urinary retention.  Mesenteric ischemia is seldom thought to be the cause. Mesenteric venous thrombosis (MVT) is a well-established cause of mesenteric ischemia. Pregnancy and puerperium being a hypercoagulable state is a risk factor for MVT.  We report the successful intensive care management of an unusual case of acute MVT in a 21-year-old woman with pre-eclampsia, hemolysis, elevated liver enzymes, low platelet (HELLP) syndrome and acute fatty liver of pregnancy (AFLP) following an uneventful vaginal delivery.
| Case Report|| |
A 21-year-old woman, who was a known case of pre-eclampsia, diagnosed to have HELLP syndrome in the postpartum period was referred to our intensive care unit (ICU) with a history of increasing epigastric pain and abdominal distension for 3 days following an uncomplicated vaginal delivery of a female child. Her first vaginal delivery, 2 years earlier, was uneventful and she had no surgical illness in the past.
On examination, she was restless, agitated but oriented to time, place and person, afebrile with a pulse rate of 128 bpm, blood pressure of 190/120 mmHg in left arm supine position and a respiratory rate of 24/min. She was pale, icteric, with bilateral pedal edema. Abdominal examination revealed ascites with mild tenderness and the presence of bowel sounds. Deep tendon reflexes were brisk. On auscultation, air entry was reduced bilaterally at the lung bases. Examination of cardiovascular system was unremarkable.
On admission, the random blood sugar was 67 mg/dl, urine examination showed proteinuria (3+), hepatitis B surface antigen and hepatitis C viral antibody were negative. Serum uric acid was 3.4 mg/dl. The investigations with which she was referred to our hospital [Table 1] and investigations carried out in our hospital are as shown in the [Table 2] and [Table 3]. Ultrasonography of chest and abdomen showed ascites and hyperechoiec liver with bilateral pleural effusion. Electrocardiogram showed sinus tachycardia and echocardiography revealed borderline left ventricular hypertrophy with a minimal pericardial effusion. The peripheral smear showed normocytic normochromic erythrocytes with occasional normoblasts, leucocytosis with reduced platelets. The provisional diagnosis of postpartum HELLP syndrome with fatty liver of pregnancy was made as the patient fulfilled the required criteria (abdominal pain, elevated bilirubin, hypoglycemia, lecocytosis, ascites with hyperechoeic liver, elevated transaminases, renal impairment, coagulopathy). She was kept nil by mouth with continuous nasogastric tube drainage and managed conservatively with optimal fluid and electrolyte balance, intravenous pantoprazole, antibiotics (ciprofloxacin and ornidazole), fresh frozen plasma (4 units) and vitamin K. Right internal jugular vein was cannulated and intake output was maintained based on central venous pressure. Blood pressure was controlled with labetalol and tramadol was given for pain relief.
|Table 1: Investigations with which the patient was referred to our hospital|
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The patient continued to have pain and distension of abdomen, despite treatment, with an increasing nasogastric aspirate. Abdominal computed tomography scan carried out on day 4, showed irregular surface of liver with scalloped margins and peripheral irregular hypodense areas in the right lobe. Multiple dilated small bowel loops with multiple air fluid levels were also noted.
Informed consent was obtained and she was taken up for emergency laparotomy under general anesthesia.
Intra-operatively, gangrene of small bowel involving ileum was noted. Gangrenous bowel was resected and end-to-end anastomosis was performed. At the end of surgery, the patient was shifted to ICU for elective ventilation. She was extubated on the second post-operative day and started on the total parenteral nutrition from day 4. Her renal functions, liver functions and serum electrolytes improved gradually. Microscopic examination of section from gangrenous part of small intestine showed features suggestive of mesenteric vein thrombosis. Antibiotic injections (ceftriaxone with sulbactum, metronidazole, ciprofloxacin) were administered from day 4 to day 20 of ICU stay.
She was discharged, after 25 days of hospital stay with tablet labetalol and warfarin.
Six months after the surgery patient expired after an acute onset of breathlessness, the details of which could not be obtained from the informants of patient.
| Discussion|| |
Acute mesenteric ischemia is a rare abdominal emergency in the postpartum period with high morbidity and mortality. A critical point that influences survival rate is early diagnosis and treatment.  MVT is well-established as a cause of intestinal ischemia that is distinct from mesenteric arterial occlusion and accounts for approximately 15% of all mesenteric ischemic cases. , Since, the symptoms are nonspecific and there are no distinct physical examination findings or laboratory abnormalities, the diagnosis is rendered difficult. In our case, coexistence of pregnancy related conditions like preeclampsia, HELLP syndrome, AFLP made the diagnosis and management a real challenge to the treating physicians.
As the patient was referred to our hospital for the management of preeclampsia, HELLP syndrome and AFLP, most of the valuable time was spent on treating the pregnancy related conditions.
Abdominal pain being a common symptom in HELLP syndrome and AFLP, any aggressive treatment is generally delayed hoping for spontaneous resolution.
HELLP syndrome is a part of the spectrum of pre-eclampsia. It is most commonly seen in the antepartum period (70%) but 30% of the cases present in the postpartum period.  Sibai has stated that postpartum HELLP syndrome usually develops within 48 h of delivery but may be seen even up to 7 days after delivery.  Most of the symptoms in our patient were in the postpartum period.
AFLP is another rare but dangerous disorder of pregnancy. It may present with non-specific symptoms and is sometimes difficult to differentiate from HELLP syndrome.  Preeclampsia occurs in approximately 50% of AFLP. 
If the diagnosis of HELLP syndrome or AFLP is established during pregnancy, the treatment of either of the two would be the termination of pregnancy and symptomatic management. However, in our case most of the symptoms seem to have evolved following delivery.
Compared to arterial causes, acute mesenteric ischemia due to venous thrombosis has a better prognosis.  Early diagnosis and prompt anticoagulation are the mainstay of therapy unless there are signs of peritonitis that necessitate surgical resection of the infarcted bowel. 
Pregnancy being a hypercoagulable state is an identified risk factor for MVT. Early use of anticoagulants decreases the morbidity, but it is difficult to judge which patients require anticoagulants unless the patient is investigated. Anticoagulants as a part of intensive care management were not considered in our patient because the coexisting HELLP and AFLP confused the diagnosis until later.
| Conclusion|| |
Very few cases of acute abdomen with HELLP syndrome and AFLP, following uneventful vaginal delivery, in a patient with preeclampsia have been reported in the literature. Diagnosis of acute surgical illness in a patient with the pregnancy related comorbid conditions pose a real challenge to the treating physician. High index of suspicion for MVT, prompt diagnosis and treatment, meticulous intensive care of such patients and good coordination between various specialties helps in rapid recovery. Judicious use of anticoagulants in selected cases can improve survival of high risk patients admitted in ICU.
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[Table 1], [Table 2], [Table 3]