puerperal venous thrombosis and pulmonary embolism

Pregnancy is an example of Virchow’s triad- hypercoagulability, stasis of blood and endothelial injury; together these factors lead to an increased incidence of venous thromboembolism [1]. /Type /Page 1. Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism, is a common cardiovascular disease associated with significant morbidity ranging from painful leg swelling, chest pain, shortness of breath, and even death. Venous thrombosis is thrombosis in a vein, caused by a thrombus. Clipboard, Search History, and several other advanced features are temporarily unavailable. 10 0 obj Furthermore, the use of thrombolytics and inferior vena cava filter in initial treatment was associated to an increased risk of VTE recurrence. 2012 Feb;52(1):14-22. doi: 10.1111/j.1479-828X.2011.01361.x. Successful low-dosage thrombolysis of massive pulmonary embolism in primigravida: A case report. NIH Diagnosis of deep vein thrombosis and pulmonary embolism are described, including the use of … air embolism complicating abortion or ectopic or molar pregnancy (O00-O07, O08.2)air embolism complicating pregnancy, childbirth and the puerperium ()air embolism following infusion, transfusion, and therapeutic injection ()air embolism following procedure NEC () Although thrombosis complication is rare after arthroscopic meniscus surgery, deep vein thrombosis and pulmonary embolism can be fatal. Puerperal ovarian vein thrombosis is dangerous. ... Puerperal ovarian vein thrombosis with extension into the inferior vena cava. Thrombophilia is an important risk factor for VTE in pregnant women and includes acquired thrombophilia and hereditary thrombophilia. Demers C, Ginsberg JS. /XObject <> Appropriate methods of prophylaxis for specific patient groups are considered. Liao J, Lai F, Xie D, Han Y, Mai S, Weng Y, Zhang Y, Du J, Zhou G. Medicine (Baltimore). 2 … In this consensus statement, we present our recommendations for the diagnosis and management of acute deep venous thrombosis (DVT) and PE. <> Because of the risk of adverse effects on the fetus, warfarin is not generally used during pregnancy. Anticoagulation with heparin is the mainstay of therapy during the pregnancy, but patients may be transitioned to warfarin after delivery. Venous thromboembolic disease is among the most common causes of morbidity and mortality during pregnancy. Initial treatment: usually a low-molecular-weight heparin. Venous thrombosis is thrombosis in a vein, caused by a thrombus (blood clot). The code is valid for the year 2020 for the submission of HIPAA-covered transactions. In the antenatal cases the ratio of deep vein thrombosis to pulmonary embolism was 3.4:1, whereas in the postnatal cases the ratio was 13.1:1, demonstrating a higher incidence rate of puerperal deep vein thrombosis than antenatal deep vein thrombosis. >> The ICD-10-CM code O88.23 might also be used to specify conditions or terms like obstetric blood-clot pulmonary embolism or obstetric blood-clot pulmonary embolism - delivered with postnatal complication. 1 0 obj Treatment: Deep venous thrombosis (DVT): occurs most often in the lowe extremities; involvement varies but can extend from the foot to the iliofemoral region iii. The guideline identifies adult patient groups at risk of venous thromboembolism and describes the available methods of prophylaxis, with general recommendations about efficacy, safety, and how they should be used. This combination is called venous thromboembolism. doi: 10.1097/MD.0000000000012985. Failure to investigate symptoms suggestive of pulmonary embolism (PE) is a consistent finding in maternal death enquiries, and clinical symptoms should not be relied on to exclude or diagnose VTE. Pulmonary embolism (PE) is the leading cause of maternal mortality in the developed world [1, 2].The incidence of PE increases during pregnancy and most often develops during the postpartum period [].Ovarian vein thrombosis, a rare complication during pregnancy, is a type of deep vein thrombosis … The clinical evaluation alone is insufficient for the diagnosis of venous thromboembolic disease, and the normal pregnant state makes this evaluation even more challenging. CT pulmonary angiography revealed right subsegmental pulmonary embolism. Venous thromboembolic disease is a significant cause of morbidity and mortality during pregnancy and the puerperal period. Thrombophilia is the overall name for a number of specific abnormalities resulting in an increased tendency towards … Risks, challenges, and recommendations. Deep vein thrombosis and pulmonary embolism, collectively referred to as venous thromboembolism, constitute a major global burden of disease. Hormone Contraception and Venous Thromboembolism. Aust N Z J Obstet Gynaecol. [1][2] [3] The clinical findings of OVT are non-specific. Assuming a normal circulation, an embolus formed in a systemic vein will always impact in the lungs, after passing through the right side of the heart. Appropriate methods of prophylaxis for specific patient groups are considered. Pelvic monary embolism was performed. < endobj 2. Case reports and case series suggest that thrombolytic therapy may be associated with lower risks of fetal loss than embolectomy. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. Potential risk factors for peripartum cerebral venous thrombosis and stroke were evaluated in a study conducted on United State National Hospital Discharge Survey data between 1979 and 1991. Epub 2017 Aug 5. Puerperal ovarian vein thrombophlebitis is a rare pathology. O88.23 is a billable code used to specify a medical diagnosis of thromboembolism in the puerperium. There is significant mortality associated with VTE events, up to 15% in the first 3 months after diagnosis , . This combination is called venous thromboembolism. 1). Abdominal–pelvic computer tomography with contrast Keywords Ovarian vein thrombosis Pulmonary medium revealed a 2.5-cm OVT having extended into the embolism Puerperium inferior vena cava for 14 cm with a slight peripheral edema. Blood Thinners A pulmonary embolism (PE) usually happens when a blood clot called a deep vein thrombosis (DVT), often in your leg, travels to your lungs and blocks a blood vessel. Epub 2011 Oct 6. The most common form of venous thrombosis is a deep vein thrombosis (DVT), when a blood clot forms in the deep veins of the leg. Deep vein thrombosis, or DVT, is a blood clot that forms in a vein deep in the body. HHS Both have risks and benefits, but both can be used safely during pregnancy. The arteriography did not show any bleeding site, but it revealed a left ureterohydronephrosis with a stop in the distal left ureter (Fig. to pulmonary embolism (25%) and death (5% of complicated cases, with estimated 18 deaths per million pregnancies).10,11 The pathogenesis of thrombus formation in the ovarian vein involves many factors. | If the thrombus breaks off and flows towards the lungs, it can become a pulmonary embolism, a blood clot in the lungs. examination was remarkable for mild right adnexal tender- ness. Puerperal or postpartum period is reported as a risk factor for superior sagittal sinus thrombosis and other cerebral venous thrombosis. USA.gov. Part 1. Table 1. Heart J. Yovember, 1969 Estrogens and puerperal thromboembolism Pulmonary embolus is now second only to abortion as a cause of maternal death in England and Wales' and 70 per cent of these deaths occur in the puerperium. <> Venous thromboembolism (VTE) includes both deep vein thrombosis (DVT) and pulmonary embolism (PE). 2017 Mar 1;95(5):295-302. 2000 Sep 15;108(4):71-2, 77-8, 81-4. doi: 10.3810/pgm.2000.09.15.1238. In fact, venous thrombosis and pulmonary embolism are so inextricably linked that today we consider 2 aspects of the same clinical entity: venous thromboembolic disease (VTD). We present the case of a 23‐year‐old female who presented with fever and cough that occurred after vaginal delivery and persisted after several courses of antibiotics between the 2nd and 20th day postpartum. Pulmonary embolus (PE) is thought to arise from a deep venous thrombosis (DVT). Ghilardi G , Giorgetti PL , Bortolani EM Panminerva Med , 33(3):152-156, 01 Jul 1991 The code O88.23 is applicable to female patients aged 12 through 55 years inclusive. Diagnosing pulmonary embolism in pregnancy: Is there a role for D-dimer as a stand-alone test? Various other forms of venous … Two case studies seem to prove the point: Case 1 A 24-year-old woman was transferred to our hospital with the chief complaint of abdominal pain radiating to the right thigh, vomit, diarrhea, and a slight pyrexia (37.6 °C rectal). Long-term complications include recurrent VTE, postpulmonary embolism syndrome, chronic thromboembolic pulmonary hypertension, and postthrombotic syndrome (PTS). A statement for healthcare professionals. stream Pulmonary embolism was relatively uncommon during pregnancy versus the postpartum period (10.6 vs. 159.7 per 100,000). Would you like email updates of new search results? 6 0 obj /Parent 84 0 R Deep Vein Thrombosis. 2006 Oct;34(10):2701; author reply 2701-2. doi: 10.1097/01.CCM.0000240786.73945.9F. Superficial venous thrombosis, deep venous thrombosis, and pulmonary embolism. COVID-19 is an emerging, rapidly evolving situation. | Lancet 345: 1326–1330, 1995 : 76. 瘟��3J*9��:�M:��o�� +�=��l�m�ӭ��LmɑX��C��1��u��W�H��1_hM��6搊� n�pʽ`�7�jc�h�y�B�"�s�P-��(�O�6� ��t�f1�T��s�t�p/T��y2%��}P�`�,܎�M'wM �ʏ�୵�Z�h��x.0��#�T. Fibrinolytics for the treatment of pulmonary embolism. The objectives of the present study were to investigate the role of haemostatic risk factors for pregnancy-related VT and their phenotypic expression in deep-vein thrombosis (DVT) and pulmonary embolism … Epub 2017 Aug 25. 2 0 obj 115(4):453-61. . 2008 Mar. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. endobj ... delivery O86.8 Other specified puerperal infections O86.81 Puerperal septic thrombophlebitis O86.89 Other specified puerperal infections O87 Venous [icd10data.com] >> Type 1 Excludes. VTE mainly includes deep vein thrombosis and pulmonary embolism. Chest X-ray can be used to validate diagnosis of pulmonary embolism, as a Myocardial infarction and stroke were reported in OCP users during the following years and were associated with older women who smoke and use HC. Postgrad Med. /Font <> 2018 Oct;97(43):e12985. The assisted reproductive technique in vitro fertilization (IVF) is associated with an increased incidence of venous thromboembolism (VTE). Transl Res. endobj 2020 Nov;225:82-94. doi: 10.1016/j.trsl.2020.05.003. <> /Length 128 McLintock C, Brighton T, Chunilal S, Dekker G, McDonnell N, McRae S, Muller P, Tran H, Walters BN, Young L; Councils of the Society of Obstetric Medicine of Australia and New Zealand; Australasian Society of Thrombosis and Haemostasis. Ghilardi G , Giorgetti PL , Bortolani EM Panminerva Med , 33(3):152-156, 01 Jul 1991 Deep vein thrombosis and pulmonary embolism in pregnancy Military Maternity Hospital 28 September 2015 D.Kahtan Sbeqi. /U <146EFDB761063C414C686D1C8B11898431415926535897932384626433832795> A deep vein thrombosis can break loose and cause a serious problem in the lung, called a pulmonary embolism. 7 0 obj 2004 Jul. VTE is more common after delivery than before delivery, and this condition can be hidden and develops rapidly. J Thromb Haemost. 115(4):453-61. . Either (unfractionated) heparin or low molecular weight heparin is an acceptable treatment for acute venous thromboembolic disease. BJOG. We present the case of a 23‐year‐old female who presented with fever and cough that occurred after vaginal delivery and persisted after several courses of antibiotics between the 2nd and 20th day postpartum. Pulmonary embolism secondary to puerperal ovarian vein thrombophlebitis. ... Puerperal ovarian vein thrombosis with extension into the inferior vena cava. Both have risks … Puerperal ovarian vein thrombophlebitis is a rare pathology. Morse M. Establishing a normal range for D-dimer levels through pregnancy to aid in the diagnosis of pulmonary embolism and deep vein thrombosis. A diagnosis of pulmonary embolism in pregnancy has important implications, including the need for prolonged anticoagulation therapy, delivery planning, and possible prophylaxis during future pregnancies, as well as concern about future oral contraceptive use and estrogen therapy (, 1–, 4). Suthar R, Abdelfattah S, Goldman H, Garcia G, Romero-Fischmann D, Escobar M, Behrens V. J Anesth. Clarke CS, Harlin SA. Hirsh J, Hoak J: Management of deep vein thrombosis and pulmonary embolism. Most likely cause is deep vein thrombosis (DVT) in the leg or in the pelvis however in BJOG. Complications include ovarian vein thrombophlebitis, which can result in sepsis, thrombosis of the inferior vena cava and renal veins, and can lead to pulmonary embolism (25%) and death (5% of complicated cases, with estimated 18 deaths per million pregnancies).10,11The pathogenesis of thrombus formation in the ovarian vein involves many factors. Deep venous thrombosis and pulmonary embolism in pregnancy. INTRODUCTION Pregnancy and the puerperium are well- established risk factors for venous thromboembolism (VTE) incidence of VTE ranging from 4 to 50 times higher in pregnant versus non- pregnant women it an absolute incidence rate of 1 in 500 to 2000 … 1-3 In a previous study a sevenfold increased incidence of pulmonary embolism (PE) was also found during the first trimester of IVF pregnancies compared to natural pregnancies. ... delivery O86.8 Other specified puerperal infections O86.81 Puerperal septic thrombophlebitis O86.89 Other specified puerperal infections O87 Venous [icd10data.com] C . The incidence of venous thromboembolism (VTE) in pregnant women is significantly higher than that in non-pregnant women. %PDF-1.3 Pelvic monary embolism was performed. CT pulmonary angiography revealed right subsegmental pulmonary embolism. We examined the relationship between DVT and PE in trauma patients screened for DVT with duplex sonography (DS). A 24-year-old nulliparous female patient underwent cesarean … Pulmonary embolism is a sudden blockage in the lung artery. The increase of this condition and its complications favored the activity in the search of diagnostic and therapeutic means aimed at solving this disturbance. [��R�vC�m�) NLM If both pulmonary embolism and deep venous thrombosis is suspected, compression ultrasonography is recommended initially. This site needs JavaScript to work properly. To determine the pregnancy-related and puerperium-related risk of venous thromboembolism in women with inherited thrombophilia, we performed a case-control study on 119 women who had a first episode of deep vein thrombosis and/or pulmonary embolism during pregnancy or puerperium and 232 healthy women who had at least one pregnancy without thrombosis. VTE encompasses both pulmonary embolism (PE) and deep vein thrombosis (DVT), both of which are major health concerns that have an annual incidence of 1–2 cases per 1000 people in western populations . Pulmonary embolism is the leading preventable cause of maternal death during pregnancy. Its occurrence simultaneously with pulmonary embolism (PE) is much rarer. Two case studies seem to prove the point: Case 1 A 24-year-old woman was transferred to our hospital with the chief complaint of abdominal pain radiating to the right thigh, vomit, diarrhea, and a slight pyrexia (37.6 °C rectal). [ncbi.nlm.nih.gov] deep vein thrombosis. Clarke CS, Harlin SA. /TrimBox [0 0 612 792] J Thromb Haemost. endobj An inflammatory mass around the ovarian and iliac veins mimicking retroperitoneal lymphadenopathv (Fig. Nat Rev Cardiol. 5. Postnatal cases comprised 235 deep vein thrombosis (ICD codes 671.4, O87.1, I80.2), 18 pulmonary embolism (ICD codes 415.1, I26) and three other venous thrombosis. Successful pulmonary embolectomy for massive pulmonary embolism during pregnancy: a case report. Pulmonary embolism secondary to puerperal ovarian vein thrombophlebitis. 3. 2, 3). Ovarian vein thrombosis, a rare complication during pregnancy, is a type of deep vein thrombosis that can lead to PE. VTE mainly includes deep vein thrombosis and pulmonary embolism. 4 0 obj /ProcSet [/PDF /Text /ImageB] <> The most common form of venous thrombosis is a deep vein thrombosis, when a blood clot forms in the deep veins of the leg. >> <> Epub 2020 May 17. 1, B). Deep vein thrombosis is the end result of several, partly interrelated, inherited and acquired risk factors. If the thrombus breaks off (it embolizes) and flows towards the lungs, it can become a pulmonary embolism (PE), a blood clot in the lungs. VTE is more common after delivery than before delivery, and this condition can be hidden and develops rapidly. The ovarian veins are frequently used to identify the ovaries, and are a useful landmark to determine the origin of a pelvic mass (ovarian vascular pedicle sign).12 Abstract. Morse M. Establishing a normal range for D-dimer levels through pregnancy to aid in the diagnosis of pulmonary embolism and deep vein thrombosis. endobj Background: <> Most deep vein clots occur in the lower leg or thigh. Diagnosis of deep vein thrombosis and pulmonary embolism are described, including the use of … Although the exact incidence of VTE is unknown, an estimated 1 million people in the United States are affected each year, with about a third experiencing a recurrence within 10 years. If diagnosis of deep venous thrombosis is confirmed, addition diagnostic tests for pulmonary embolism are not generally required . examination was remarkable for mild right adnexal tender- ness. If the vein swells, the condition is called thrombophlebitis. Introduction. However, the precise time of the VTE initiation of deep venous thrombosis and pulmonary embolism was 5.8 and 8.0 days before admission, respectively, according to chart review, which would move some VTEs categorized as puerperal to late pregnancy. Venous thromboembolism manifests as deep venous thrombosis (DVT) or pulmonary embolism, and has a mortality rate of 6 to 12 percent. The guideline identifies adult patient groups at risk of venous thromboembolism and describes the available methods of prophylaxis, with general recommendations about efficacy, safety, and how they should be used. This will form a pulmonary embolism that will result in a blockage of the main artery of the lung and can be a complication of deep-vein thrombosis.The most common sites of origin of pulmonary emboli are the femoral veins. Also called: DVT. 3 0 obj There is an associated high risk of pulmonary embolism and … We report a case of 24-year-old woman with a history of Behçet's disease, who presented with pelvic and thoracic pain, tachycardia, dyspnea and fever occurring 2 weeks after delivery. In general, the incidence of cerebral venous thrombosis, of which superior Intravenous heparin is the treatment of choice surrounding delivery due to its short half life. 2013 Jul;10(7):397-409. doi: 10.1038/nrcardio.2013.73. Over the 30-year study period, the incidence of venous thromboembolism during pregnancy remained relatively constant whereas the postpartum incidence of pulmonary embolism decreased more than 2-fold. Annual incidence rates for venous thromboembolism in pregnancy. endobj Ovarian vein thrombosis is a rare and severe puerperal complication that usually manifests as fever and abdominal pain in the puerperal period and is more frequent in women who have undergone cesarean section. Am Fam Physician. endobj /StructParents 90 Objective testing is the mainstay of diagnosis, including compression ultrasound, impedance plethysmography, ventilation-perfusion scanning, computed tomography scanning, and pulmonary angiography. CONCLUSIONS: The current study provides new insights on VTE recurrence rate in patients with deep vein thrombosis (DVT) or pulmonary embolism (PE) that occurred in pregnancy or postpartum period. %�쏢 Wells PS, Hirsh J, Anderson DR et al: Accuracy of clinical assessment of deep vein thrombosis. Pre-eclampsia and acute pulmonary embolism-the importance of making a differential diagnosis: a case report. <> VTE is more common after delivery than before delivery, and this condition can be hidden and develops rapidly. KEY WORDS: Embolism, puerperium, pulmonary, sagittal sinus, thrombosis Case Report INTRODUCTION Superior sagittal sinus thrombosis is a relatively rare and often misdiagnosed condition. Oral anticoagulants in the management of venous thromboembolism. Pulmonary embolism (PE) is the leading cause of maternal mortality in the developed world [1, 2]. Taenaka H, Ootaki C, Matsuda C, Fujino Y. JA Clin Rep. 2017;3(1):44. doi: 10.1186/s40981-017-0116-3. The incidence of PE increases during pregnancy and most often develops during the postpartum period [3]. Please enable it to take advantage of the complete set of features! 9 0 obj 2. Complications include ovarian vein thrombophlebitis, which can result in sepsis, thrombosis of the inferior vena cava and renal veins, and can lead to pulmonary embolism (25%) and death (5% of complicated cases, with estimated 18 deaths per million pregnancies).10, 11 The pathogenesis of thrombus formation in the ovarian vein involves many factors. ��׷x�G��? Am Fam Physician. Women giving birth after fresh embryo transfer IVF had a more than eightfold increased incidence of venous thromboembolism (hazard ratio [HR] 8.96, 95% CI 6.33 to 12.67) and pulmonary embolism during the first trimester, (HR 8.69, 95% CI 3.83 to 19.71) compared to women giving birth after natural conception. Unstable pulmonary embolism is difficult to treat during pregnancy, as there are minimal data regarding the safety and efficacy of thrombolytic therapy, inferior vena cava filters, and embolectomy during pregnancy. Recommendations for the diagnosis and treatment of deep venous thrombosis and pulmonary embolism in pregnancy and the postpartum period. The annual incidence rates ranged from 60/100,000 maternities in 1995 to 117/100,000 maternities in 1997. Abdominal–pelvic computer tomography with contrast Keywords Ovarian vein thrombosis Pulmonary medium revealed a 2.5-cm OVT having extended into the embolism Puerperium inferior vena cava for 14 cm with a slight peripheral edema. OVT can cause serious complications such as sepsis, IVC thrombosis, renal vein thrombosis and pulmonary thromboembolism which develops in 13% of cases, with a 4% mortality risk.10 11. endobj 2013 Apr;22(137):99-101, 103-4. Prescrire Int. Apr 28, 2020 The incidence of venous thromboembolism (VTE) in pregnant women is significantly higher than that in non-pregnant women. Crit Care Med. METHODS: A hospital-based retrospective case-control study of all postpartum thromboembolic instances of deep venous thrombosis and pulmonary embolisms during a … Epub 2013 May 21. Puerperal Pulmonary Thrombosis, with an Illustrative Case. 1. Although thrombosis complication is rare after arthroscopic meniscus surgery, deep vein thrombosis and pulmonary embolism can be fatal. Management of VTE requires immediate anticoagulation therap… 8 0 obj Knight M,. �6?�R��/�|vb)�j��?d�s�R�To� ��x��4N��C/3�#��[��_�hm�Ca5�>��ޔ�ư$� ܡm�|� F�V!��w��o�z�C��j� <> Thromboembolism during pregnancy. The diagnostic work-up of suspected deep vein thrombosis or pulmonary embolism includes the sequential application of a clinical decision rule and D-dimer testing. Recent data suggest that PE can present without DVT, inferring that PE can originate de novo (DNPE). VTE mainly … 720 Annotations Am. Either (unfractionated) heparin or low molecular weight heparin is an acceptable treatment for acute venous thromboembolic disease. endobj Ovarian vein thrombosis (OVT) is an uncommon but potentially serious complication in the early postpartum. Diagnosis: It is clinically and virtually i… Treatment: If deep vein thrombosis or pulmonary embolism is diagnosed, anticoagulation should be initiated. | 5 0 obj All of these tests can be safety performed during pregnancy. A computed tomography was performed, showing right ovarian vein thrombosis extending into the inferior vena cava and asymptomatic pulmonary embolism (Fig. (Pg 243) Saphenous vein of lower leg and is a painful, hard, red, warm vein ... What are the risk factors for puerperal sepsis in the postpartum woman? Superficial venous thrombosis: involvement of the superficial saphenous venous system ii. /Rotate 0 >> DVT and PE are both forms of VTE, … Deep Venous Thrombosis and Pulmonary Embolism: Current Therapy. The first case of thrombosis associated with HC occurred in 1961 when a nurse taking a high-dose estrogen OCP developed a pulmonary embolism. Ovarian vein thrombosis (OVT) is an uncommon but potentially serious complication in the early postpartum. Venous thromboembolism (VTE) is a disease that includes deep vein thrombosis (DVT) and pulmonary embolism (PE). 2004 Jul. We present herein, a rare case of severe VTE caused by thrombophilia in the puerperium period. 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( VTE ) in pregnant women of making a differential diagnosis: a case report is an acceptable treatment acute. All of which are potentially life-threatening PDF-1.3 % �쏢 1 0 obj < endobj. 81-4. doi: 10.3810/pgm.2000.09.15.1238 a deep vein thrombosis ( VT ) during pregnancy: is there a for... Thrombosis: involvement of the superficial saphenous venous system ofthe lower extremities collectively referred to as thromboembolism...... puerperal ovarian vein thrombophlebitis 31 ( 6 ):903-906. doi: 10.1038/nrcardio.2013.73,! Like email updates of new search results rates ranged from 60/100,000 maternities in 1997 during. Garcia G, Romero-Fischmann D, Escobar M, Behrens V. J Anesth Jul 1991 Introduction 1, ]! Vte events, up to 15 % in the puerperium period syndrome, chronic thromboembolic pulmonary hypertension, and a... Are not generally used during pregnancy and most often develops during the following and... 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