Dr Esther Park1, Miss Mandish Dhanjal1, Dr Carolyn Millar1, Dr Vinnie Sodhi1, Miss Naomi Primrose1, Ms Sahana Gupta2, Dr Charlotte Frise1
1Imperial College Healthcare NHS Trust, London, United Kingdom, 2London North West University Healthcare NHS Trust, London, United Kingdom
Biography:
Dr Esther Park is a clinical training fellow in obstetric medicine at Queen Charlotte's and Chelsea Hospital, London. She has a background in acute internal medicine.
Abstract:
Introduction: CVST is a neurological emergency caused by occlusion of the dural venous sinus and/or the cerebral veins. It is more common in women during pregnancy and puerperium(1). We present a case of a woman with an expanding CVST who had a successful vaginal delivery with meticulous anticoagulation and labour management, MDT input and close monitoring.
Case: A 26-year-old nulliparous woman presented at 26 weeks of gestation with 4-week history of worsening left retro-orbital pain, which had been sudden in onset. A diagnosis of cavernous sinus thrombus was made at 36 weeks’ gestation after she re-presented with worsening headache, vomiting and horizontal diplopia. Anticoagulation with low molecular weight heparin (LMWH) was started, but at 38 weeks, her symptoms worsened and imaging showed expansion of the thrombus. Anti-Xa was below the target range consistent with the dose being subtherapeutic. An MDT was convened and the risks of caesarean and vaginal delivery discussed. This was then discussed with the patient who preferred to pursue vaginal delivery. Anticoagulation during the induction process was with unfractionated heparin (UFH) infusion and regular anti-Xa monitoring. Four hours after the infusion was paused, the baby was born by forceps. Blood loss was minimal and therapeutic anticoagulation with heparin infusion resumed after 4 hours, and switched to treatment dose LMWH when she was stable. Her neurological symptoms improved gradually after delivery.
Learning points: -Caesarean delivery may be perceived as a safer mode of delivery due to concerns about therapeutic anticoagulation and high intracranial pressure, but is associated with higher risk of bleeding and thrombosis compared to uncomplicated vaginal delivery
-Uncomplicated vaginal delivery facilitated earlier postpartum anticoagulation
-UFH infusion monitoring with anti-Xa is preferred to APTT due to the change in factor VIII levels in the third trimester, which can lead to apparent heparin resistance and misleadingly low APTT
Keywords
cerebral venous sinus thrombosis, high intracranial pressure, vaginal delivery
References
(1) Algahtani H, Bazaid A, Shirah B, Bouges RN. Cerebral venous sinus thrombosis in pregnancy and puerperium: A comprehensive review. Brain Circ. 2022 Dec 6;8(4):180-187. doi: 10.4103/bc.bc_50_22. PMID: 37181848; PMCID: PMC10167849.
Frise C, Collins S. Oxford Handbook of Obstetric Medicine. 1st ed. Oxford: Oxford University Press; 2020.