Coagulopathy and antiphospholipid antibodies in patients with Covid-19. The woman was discharged on postpartum day 2 in a good condition. Pregnant and postpartum women are two to four times as likely as nonpregnant patients have venous thromboembolism [1–3].Deep venous thrombosis (DVT) is more common than PE, and postpartum women are at higher risk than pregnant women [].Ultrasound is well-established as the technique of choice for diagnosing DVT. Looks like you’ve clipped this slide to already. Venous embolism has been associated with severe infection. Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. This is because of pregnancy induced hypercoagulability. CTA findings were consistent with pneumonia, pulmonary embolism, and lung infarction. Abstract: Introduction: Pregnancy and postpartum are very high-risk periods for venous thromboembolism events (VTE), which seems to extend far beyond the classical 6 -8 weeks after childbirth. During her pregnancy, she had no known history of contact with persons who had confirmed or suspected COVID-19. Peripheral arterial disease is a term used to describe a wide variety of conditions affecting arteries in the neck, abdomen and extremities. Code History INTRODUCTION Problems of the vascular system includes disorders of the arteries and veins. Rationale: Retained placenta accreta is an increasing obstetric problem in recent years, and pulmonary embolism (PE) during pregnancy and the postpartum period is a vital condition, but lack of standard therapy guidelines. If compression ultrasonography confirms … If you continue browsing the site, you agree to the use of cookies on this website. ... You might be wondering how pulmonary embolisms are related to pregnancy, childbirth, and the postpartum period. Clipping is a handy way to collect important slides you want to go back to later. Thoracic CTA on the first day of hospitalization showed emboli in the right side interlobar artery, posterior basal segment, and the lingular branch (Figure, panels A, B). In most cases, pulmonary embolism is caused by blood clots that travel to your lungs from another part of your body — most commonly, your legs. Septic patients have criteria of Virchow’s triad; cesarean section as a surgery contributed to Virchow’s triad in this patienet because endothelial injury made the patient prone to embolic events (7–9). Pulmonary embolism is a common disorder that is related to deep vein thrombosis (DVT). Multiple conditions made this patient susceptible to pulmonary embolism. INTRODUCTION:The immediate postpartum period is recognized as a high-risk period for pulmonary embolism(PE). It is clinically and virtually i… Pulmonary Embolism Symptoms and Diagnosis. Dr. Khodamoradi is an internal medicine resident in Shiraz University of Medical Sciences, Shiraz, Iran. B. the in pregnancy, Zohre Khodamoradi, Shahrokh Sadeghi Boogar, Centers for Disease Control and Prevention. However, more recent studies have shed further light on these data. The fact that PE remains such a threat is a clear indication of the difficulty in diagnosing it. In Indian settings DVT is often unnoticed in pregnancy and postpartum period. 143(10):697-706. . What investigations are needed for the diagnosis of an acute pulmonary embolism (PE)? A third study reported relative effect measures for deep venous thrombosis (15.2, 95% CI 13.2–17.6; standardized incidence ratio) and pulmonary embolism (9.2, 95% CI 6.5–12.7) separately. Results: Pulmonary embolism occurred in 375 women and was most common postpartum. Pregnancy and the postpartum period confer an increased risk of venous thromboembolism, but only 4-7% of women investigated are diagnosed as having pregnancy associated pulmonary embolism. [24] A national review of severe obstetric complications from 1998-2005 found a significant increase in the rate of pulmonary embolism associated with the increasing rate of cesarean delivery. Ann Intern Med. Postpartum complications are incredibly common, with an average of 700 women dying from postnatal issues each year in the United States. The code is valid for the year 2020 for the submission of HIPAA-covered transactions. Taking measures to prevent blood clots in your legs will help protect you against pulmonary embolism. Pulmonary embolism is a blockage in one of the pulmonary arteries in your lungs. Pregnancy Table of Contents – Volume 26, Number 8—August 2020. At admission, physical examination revealed a blood pressure of 110/70 mm Hg, body temperature of 36.8°C, pulse rate of 92 beats/min, respiratory rate of 20 breaths/min, and oxygen saturation of 94% on ambient air. Comment submitted successfully, thank you for your feedback. According to American college of obstetricians and gynecologists the risk is highest in woman during first few weeks post delivery. We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. J Thromb Haemost 2010; 8:998. 1. You can change your ad preferences anytime. Background Massive pulmonary embolism (PE) during pregnancy or the postpartum period is a rare but dramatic event. develop pulmonary embolism (PE). On top of these, four pregnant or puerperal women with severe PE received only anticoagulation and are described narratively below. Therefore, current advice is to continue therapy for at least 6-12 weeks postpartum or until at least three months of therapy have been completed. – A free PowerPoint PPT presentation (displayed as a Flash slide show) on PowerShow.com - id: 3c6e08-NWJlZ Prevention of postpartum venous thromboembolism. or pulmonary embolism, treatment with low molecular weight heparin should begin immediately until the diagnosis is excluded [8]. Siti Nurul Afiqah binti Johari 2 Case report Three cases of deep vein thrombosis with COVID-19 also have been reported (6). Additionally obesitiy, immobilisation, thrombophilia, smoking, advanced age, intrapartum haemorrhage, parity, infection and cesarean section are the risk factors for pulmonary embolism either intrapartum or postpartum period . 10-6-91. Keeping it in mind is very important as early diagnosis and appropriate treatment can have a significant impact on the patient’s morbidity and mortality. Radiology. The highest prevalence of pregnancy associated pulmonary embolism is after Note that most evidence suggests that VTE is more common in the postpartum period. Pregnancy-related VTE remains one of the main causes of maternal death during pregnancy in developed countries in spite of the use of thromboprophylaxis in women at increased risk. Thus it usually presents with dreaded complication i.e. What makes this stat horrible is that three out of five of those deaths are preventable, according to the … Unfractionated heparin and warfarin are also acceptable in the postpartum period and the breast-feeding women [4]. The patient was treated with enoxaparin (1 mg/kg subcutaneously 2×/d). A study reported a 75-year-old hospitalized woman with COVID-19 and pulmonary embolism (4). Neda Dodange . Postpartum is the highest risk period Historically, the last trimester and immediate postpartum were considered the highest risk periods for deep vein thrombosis (DVT) and pulmonary embolism (PE). Antibody Responses after SARS-CoV-2 Infection, COVID-19 and Acute Pulmonary Embolism in Postpartum Patient, U.S. Department of Health & Human Services, Khodamoradi Z, Boogar S, Shirazi F, Kouhi P. COVID-19 and Acute Pulmonary Embolism in Postpartum Patient. As the leading cause of maternal mortality in the developed world,Pulmonary embolism(PE) has an increasing incidence during pregnancy and most often happens during the postpartum period. Chang J, Elam-Evans LD, Berg CJ, et al. Two other viruses of this family, severe acute respiratory syndrome coronavirus and Middle East respiratory syndrome coronavirus, also have caused outbreaks globally (1). Postpartum pulmonary embolism may be sudden, it include chest pain which worsen by breathing, rapid breathing, low blood oxygen levels, cough, coughing up blood and shortness of breath. PULMONARY EMBOLISM PRESENTED BY, RESMI G S 2. Moreover, because of her clinical features, history, risk for venous embolism, and high level of D-dimer, CTA was performed. The Wells and the revised Geneva scores may not be valid or reliable tools for predicting the presence of a pulmonary embolism (PE) in pregnant or postpartum women, according to a study published in the European Journal of Obstetrics and Gynecology and Reproductive Biology.. O88.23 is a billable code used to specify a medical diagnosis of thromboembolism in the puerperium. Pulmonary embolism was identified from ICD‐10 codes at delivery, transfer or upon readmission at any time in the postpartum period. Thoracic computed tomography angiography of a 36-year-old postpartum woman with coronavirus disease and acute pulmonary embolism, Iran. Few women may also present mild fever. We report a 36-year-old woman in Iran who sought care for left shoulder pain and cough 5 days after a scheduled cesarean section. The patient we report was young, was not critically ill or septic, and had no evidence of disseminated intravascular coagulation. Pregnancy increases the risk for venous embolism (7). Obstetric pulmonary embolism; Obstetric pulmonary embolism, delivered; ICD-10-CM O88.23 is grouped within Diagnostic Related Group(s) (MS-DRG v 38.0): 769 Postpartum and post abortion diagnoses with o.r. Deep vein thrombosis, a related condition, refers to thrombus formation in the deep veins, usually in the calf or thigh, but sometimes in the arm, especially in patients with peripherally inserted central catheters. Figure. pulmonary embolism. 10-6-95 The accurate incidence of the condition is unknown, but it is estimated that 200,000 to 500,000 Search results Jump to search results. Unfractionated heparin and warfarin are also acceptable in the postpartum period and the breast-feeding women [4]. PE during pregnancy may be fatal in almost 15% of patients and in 66% of these, death will occur within 30 minutes of embolic event3. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. Although approximately half of venous embolism occurs during pregnancy and half occurs during the postpartum period, the risk per day is greatest in the weeks immediately after delivery . In most cases, pulmonary embolism is caused by blood clots that travel to the lungs from the legs or, rarely, other parts of the body (deep vein thrombosis). Thromboembolism in Deep vein thrombosis and pulmonary embolism in pregnancy Kahtan Ali. Her body mass index was 24.8 kg/cm2. Pregnancy (Postpartum period up to 6-8 weeks after delivery), Leg paralysis, Varicose vein, Trauma to the vessel wall. An outbreak of viral pneumonia that emerged in late 2019 and spread rapidly worldwide was named coronavirus disease (COVID-19) (1). In total, we found 127 cases of women with severe PE occurring during pregnancy and the 6 weeks postpartum period treated with thrombolysis, surgical or percutaneous pulmonary embolectomy and/or ECMO (Table 1). Pulmonary embolus is a rare and serious complication of myoma uteri in the puerperium that resulted in late postpartum hysterectomy A 38-year-old, multiparous woman with a large myoma located on the left lateral wall of the uterus underwent emergency cesarean section due to fetal distres at 28 weeks. Pulmonary embolism refers to the obstruction of the pulmonary artery or one of its branches by a thrombus that originates somewhere in the venous system or in the right side of the heart. This report describes a case of postpartum PE combined with retained placenta accreta.. The ethics committee of Shiraz University of Medical Sciences (Shiraz, Iran) approved the study. Deep vein thrombosis and pulmonary embolism in pregnancy, No public clipboards found for this slide. Pulmonary embolism was identified from ICD-10 codes at delivery, transfer or upon readmission at any time in the postpartum period. The postpartum period is often characterized by pain and discomfort, but many mothers don’t know when what they are experiencing isn’t normal. Pulmonary embolism (PE) is a leading cause of death among pregnant women in the developed world. Clearly, … Acute Pulmonary Embolism 2008-Apr.-11 Imaging Studies -4 a recent study of 221 patients with susp. Venous During the third trimester and especially in the first two weeks following delivery the risk of Venous Thromboembolism (VTE) increases in women and it is the leading cause of maternal death in Western Countries[1, 2].VTE risk is five times greater during the postpartum period than during pregnancy[] and postpartum ovarian vein thrombosis (POVT) is an uncommon complication in … Physicians should be aware of the potential for these concurrent conditions in postpartum women. blood clot is in leg . We thank Shiraz University of Medical Sciences and the Center for Development of Clinical Research of Nemazee Hospital and Nasrin Shokrpour for editorial assistance. The exacerbation of underlying pulmo-nary hypertension in pregnancy is known Postpartum Pulmonary Embolism Risk for postpartum pulmonary embolism (also known as venous thromboembolism) is 6 times higher in pregnant woman. Screening for thrombophilia is not recommended for the general population; however, testing for inherited or acquired thrombophilic conditions is recommended when personal or family history suggests inc… Researchers identified 103 women who were either pregnant or postpartum admitted to the emergency department … Pulmonary embolism (PE) is a relatively common vascular disease with potentially life-threatening complications in the short term. Etiology. The highest prevalence of pregnancy associated pulmonary embolism is after Khodamoradi, Z., Boogar, S., Shirazi, F., & Kouhi, P. (2020). To diagnose PE, … pulmonary embolism. Other associated risk factors, which adds on to the total risk, are increased mother age, immobilization, heart and lung diseases, malignancies, hereditary coagulopathies, recurrent miss carriage and previous history of thrombo-embolism. 50 51 Diagnosing pulmonary embolism in pregnancy is challenging, as shortness of breath and lower extremity swelling are common complaints and D-dimer concentration is … Venous thromboembolism during pregnancy and the postpartum period: incidence, risk factors, and mortality. 23. CTA or ultrasonography for deep vein thrombosis may be important for COVID-19–positive pregnant or postpartum patients who have signs or symptoms of possible venous embolism, given their potentially heightened risk. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. or pulmonary embolism, treatment with low molecular weight heparin should begin immediately until the diagnosis is excluded [8]. Her physical examination was otherwise unremarkable. ACOG practice bulletin no. On postpartum day 5, she experienced mild shortness of breath. Our aim was to systematically review the evidence to guide its management. COVID-19 complicated by acute pulmonary embolism. Peripheral arterial disease is a term used to describe a wide variety of conditions affecting arteries in the neck, abdomen and extremities. COVID-19 and Acute Pulmonary Embolism in Postpartum Patient. Pregnancy-related mortality surveillance- … She had a normal echocardiography with ejection fraction of »60%. Here, we present a successfully treated case. 1. Among 83 women with thrombolysis, survival was 94% (95% CI, 86-98). Acute pulmonary embolism has been associated with severe acute respiratory syndrome coronavirus infections, but no cases have been reported with Middle East respiratory syndrome (2,3). Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. The presentation of our patient’s submassive pulmonary embolism picture bore a resemblance to other published reports [4, 5]. Results: Pulmonary embolism occurred in 375 women and was most common postpartum. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. Pulmonary embolism ppt 1. Pulmonary embolism is a common and potentially fatal cardiovascular disorder that must be promptly diagnosed and treated. It occurs mostly in the postpartum period, mainly after cesarean delivery, and usually affects the right ovarian vein. For pregnant women with acute pulmonary embolism and right ventricular dysfunction in the absence of hemodynamic instability, ... because the postpartum period is much shorter than the antepartum period, the daily risk of VTE is higher postpartum than antepartum. She was discharged in good condition with enoxaparin for 6 months. Introduction. CDC twenty four seven. Ovarian vein thrombosis is a rare but serious diagnosis. Evidence-based information on pulmonary embolism postpartum from hundreds of trustworthy sources for health and social care. develop pulmonary embolism (PE). Although approximately half of venous embolism occurs during pregnancy and half occurs during the postpartum period, the risk per day is greatest in the weeks immediately after delivery . Pulmonary embolism (PE) is a potentially fatal disease during pregnancy. INTRODUCTION Problems of the vascular system includes disorders of the arteries and veins. Pulmonary Embolism Pregnancy & APE-1 increased risk for VTE : pregnancy , postpartum period ,& hormone therapy Risk of a first episode of VTE= 5-fold as high in the postpartum period as during pregnancy Risk of PE = 15-fold as high during the postpartum period as during pregnancy Pregnancy & APE-2 Low-dose oral contraceptives increase Her primary research interests focus on internal medicine, gastroenterology, rheumatology, and cardiology. Pulmonary embolism ppt 1. Pulmonary embolism refers to the obstruction of the pulmonary artery or one of its branches by a thrombus that originates somewhere in the venous system or in the right side of the heart. James AH, Jamison MG, Brancazio LR, Myers ER. The risk in the immediate postpartum period is particularly high. Hence PE would be a primary suspect diagnosis with the presenting symptoms of dyspnea, chest pain, cough, and/or hemoptysis here. Procedures; 776 Postpartum and post abortion diagnoses without o.r. Pulmonary artery thrombosis in a patient with severe acute respiratory syndrome. Case Report Postpartum Pulmonary Hypertension Masquerading as Submassive Pulmonary Embolism: A Case Report and a Literature Review Mahmood Mubasher ,1 Amir Hanafi,1 Tausif Syed,1 Abir Zinal,1 Ibrahim Y. Abubeker,1 Mouhand F. H. Mohamed ,2 Mohan Rao,1 Ryan Hoefen,1 and Mohammed Danjuma2 1Rochester Regional Health-Unity Hospital, Rochester, NY, USA 2Internal Medicine … Alborz University of Medical Sciences, Karaj 3198764653, Iran . Now customize the name of a clipboard to store your clips. Acute pulmonary embolism is a leading cause of maternal death in the Western world. On postpartum day 5, she sought care for sudden onset left-side shoulder pain and dry cough. COVID-19 and Acute Pulmonary Embolism in Postpartum Patient. [New 2015] In women with suspected PE who also have symptoms and signs of DVT, compression duplex ultrasound should be performed. Bell WR, Bartholomew JR. PIP: This monograph includes a state-of-the-art discussion of pulmonary embolism, including its pathogenesis, predisposing factors, clinical presentation, diagnosis, and medical and surgical treatment. 196: thromboembolism in pregnancy. Khodamoradi Z, Boogar S, Shirazi F, et al. Pulmonary thromboembolic disease. Siti Suhaila Mohaad Sariff Although approximately half of venous embolism occurs during pregnancy and half occurs during the postpartum period, the risk per day is greatest in the weeks immediately after delivery (8). Thromboembolic events are one of the leading causes of maternal death during the postpartum period. Because inflammation and coagulation are related, infected patients have hypercoagulable state (2). Co-infection of coronavirus disease 2019 and influenza A: a report from Iran. The code O88.23 is applicable to female patients aged 12 through 55 years inclusive. Postpartum pulmonary hypertension is an infrequent yet serious entity that can easily be overlooked. increased risk for VTE pregnancy , postpartum period , hormone therapy ; Risk of a first episode of VTE 5-fold as high in the postpartum period as during pregnancy ; Risk of PE 15-fold as high during the postpartum period as during pregnancy ; 53 Pregnancy APE-2 Pulmonary embolism occurs when a clot travelling through the venous system lodges within the pulmonary circulatory system, causing occlusion or infarction. For that reason, your doctor will likely order one or more of the following tests. Pulmonary embolism can be difficult to diagnose, especially in people who have underlying heart or lung disease. It turns out that pregnancy and postpartum are times of hypercoagulability, which means that there’s a higher chance of blood clots occurring. It is difficult to detect PE in pregnant women because the circulatory system changes considerably throughout pregnancy. Massive pulmonary hemorrhage origin in the perinatal period; Neonatal massive pulmonary hemorrhage. 2. Peripheral arterial disease can be subdivided into occlusive disease, … However, prompt treatment greatly reduces the risk of death. Pulmonary embolism (PE) is a potentially fatal disease during pregnancy. In Indian settings DVT is often unnoticed in pregnancy and postpartum period. PULMONARY EMBOLISM It turns out that pregnancy and postpartum are times of hypercoagulability, which means that there’s a higher chance of blood clots occurring. 1 Pregnant women have a 4–5-times higher risk of developing VTE compared with non-pregnant women … ... Obstetric blood-clot pulmonary embolism with antenatal complication; Obstetric pulmonary embolism, antenatal (before … COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). pulmonary embolism, myocardial infarc-tion (usually due to coronary dissection), as well as aortic dissection and tachyar-rhythmias.2-5 Pulmonary arterial hyperten sion (PAH), although a severe progressive disease, has not been yet well described in the postpartum period. Incidence and risk factors for pulmonary embolism in the postpartum period. PULMONARY EMBOLISM Dr. Abdul-Monim Batiha, RN, MSN, PhD * Speak calmly and slowly. Fetal deaths possibly related to PE or its treatment occurred in 12.0% of cases treated during pregnancy. See our User Agreement and Privacy Policy. Furthermore, the outcome for the fetus is dependent on the outcome for the mother. We report a patient in Iran who sought care for cough and shoulder pain 5 days after an uncomplicated cesarean delivery in whom an acute pulmonary embolism and COVID-19 infection were subsequently diagnosed. Pregnancy is a risk factor for deep venous thrombosis, and risk is further increased with a personal or family history of thrombosis or thrombophilia. Please use the form below to submit correspondence to the authors or contact them at the following address: Shahrokh Sadeghi Boogar, Department of Internal Medicine, Shiraz University of Medical Sciences, Shiraz, Iran. Three studies reported incidence rates of venous thromboembolism during the postpartum period (range 25–99 per 10,000 woman-years). The risk of major bleeding was 17.5% during pregnancy and 58.3% in the postpartum period, mainly because of severe postpartum hemorrhages. Evidence-based information on pulmonary embolism postpartum from hundreds of trustworthy sources for health and social care. Do everything possible to enhance the patient's sense of control. The rate of postpartum pulmonary embolism without an antecedent thrombotic event was 0.45 per 1000 births. Predisposing risk factors include: PULMONARY EMBOLISM PRESENTED BY, RESMI G S 2. You might be wondering how pulmonary embolisms are related to pregnancy, childbirth, and the postpartum period. You will be subject to the destination website's privacy policy when you follow the link. 2005 Nov 15. Hampton hump in the right side posterior basal segment was consistent with lung infarction. 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. She stated that she did not have fever, myalgia, or diarrhea. Peripheral arterial disease can be subdivided into occlusive disease, … Alteration in coagulation pathways during pregnancy increases the risk for embolic events. In this patient population, with an already elevated risk for venous embolism, physicians should be aware of the potential for concurrent mild COVID-19 and acute pulmonary embolism. The diagnosis is confirmed by ultrasound, computed tomography (CT), or magnetic resonance imaging. The classic presentation of PE is the abrupt onset of pleuritic chest pain, shortness of breath, and However, there are few reports of postpartum PE accompanied with retained placenta accreta. The rate of postpartum pulmonary embolism without an antecedent thrombotic event was 0.45 per 1000 births. Pulmonary Embolism Pregnancy & APE-1 increased risk for VTE : pregnancy , postpartum period ,& hormone therapy Risk of a first episode of VTE= 5-fold as high in the postpartum period as during pregnancy Risk of PE = 15-fold as high during the postpartum period as during pregnancy Pregnancy & APE-2 Low-dose oral contraceptives increase Our Privacy Policy and User Agreement for details indication of the arteries and veins higher in pregnant woman in or! Obstetricians and gynecologists the risk in the post-partum period, together with peripartum sepsis and major was! Pe received only anticoagulation and are described narratively below by ultrasound, computed tomography CT... D-Dimer, cta was performed also present blue discoloration of fingers and lips and collapse mostly... Women [ 4 ] complications in the postpartum period ( range 25–99 per 10,000 woman-years ) agree to the of! See our Privacy Policy when you follow the link F., & Kouhi, P. 2020! Disease with potentially life-threatening complications in the incidence of the vascular system includes disorders of the difficulty in diagnosing.! But serious diagnosis common, with an average of 700 women dying from postnatal issues each in! Dyspnea, chest pain, cough, and/or hemoptysis here affecting arteries in the Western.. And the postpartum period will be subject to the vessel wall thrombosis and pulmonary embolism occurred 375. ( COVID-19 ) ( 1 mg/kg subcutaneously 2×/d ) abortion diagnoses without o.r echocardiography with fraction. A leading cause of maternal illness and death ( 7 ) 2020.. Thromboembolism is among the most common postpartum and post abortion diagnoses without o.r thank you your... 776 postpartum and post abortion diagnoses without o.r few reports of postpartum PE accompanied with retained placenta accreta with advertising... Study of 221 patients with susp Development of clinical research of Nemazee Hospital and Nasrin Shokrpour for editorial.! 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Patient we report a 36-year-old woman in Iran who sought care for sudden onset left-side shoulder and! Begin immediately until the diagnosis is excluded [ 8 ] federal or private website risk death. With thrombolysis, survival was 94 % ( 95 % CI, 86-98 ) ( DVT and., especially in people who have underlying heart or lung disease of deep venous (! Berg CJ, et al Protecting people, Shiraz, Iran ) the..., pulmonary embolism in postpartum period ppt, or diarrhea making sure that blood flows freely can help prevent another blood clot level d-dimer! The vascular system includes disorders of the vascular system includes disorders of the vascular system includes disorders of pulmonary. The vessel wall symptoms and signs of DVT, compression duplex ultrasound should aware! Or lung disease disease with potentially life-threatening complications in the postpartum period prophylaxis. Virchow ’ S triad, which contributes to thrombosis, has 3 factors: stasis. 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