The estimated number of live births in the U.S. in 2007 was 14.16
per 1000 population; the majority of these were after healthy pregnancies
that led to healthy births. Maternal mortality has decreased from
850 maternal deaths per 100,000 live births in 1900 to 7.5 maternal
deaths per 100,000 live births in 1982. Since 1982, however, there
have been no further decreases in maternal mortality rates. The
goal of Healthy People 2010 is no more than 3.3 maternal deaths
per 100,000 live births per year.1
Approximately 15 per 100 pregnancy-related hospitalizations in the
U.S. are due to a complication of pregnancy, costing >$1
billion annually.2 Emergency physicians must be
able to recognize and manage the myriad of conditions that can complicate
the course of pregnancy.
Thromboembolic disease, which includes deep venous thrombosis
(DVT) and pulmonary embolism (PE), is the leading cause of maternal
morbidity and mortality in the U.S. and other industrial nations
and a significant cause of fetal morbidity and mortality. Thromboembolism
accounts for almost 20% of pregnancy-related deaths in
the U.S. and complicates an average of 1 in 1000 pregnancies per
Pregnancy induces a hypercoagulable state, and the pregnant woman
is five to ten times more likely to develop DVT and PEthan the nonpregnant patient.
Pregnancy-related hypercoagulability has multifactorial causes and
may be related to the hematologic and physiologic changes that occur
during pregnancy. Hematologic changes include increases
in levels of clotting factors, increased platelet and fibrin activation,
and decreased fibrinolytic activity. These changes contribute to
the hypercoagulable state, which is essential to prevent maternal
hemorrhage during various stages of pregnancy and labor. Other physiologic changes
include venous distention and consequent venous stasis, which begin
early in pregnancy.4 An enlarging uterus may contribute
to compression of the iliac veins, further contributing to venous
Maintaining a high clinical suspicion is essential for the evaluation
and diagnosis of DVT and PE, because delayed diagnosis is associated
with significant morbidity and mortality. Traditional signs and
symptoms of thromboembolic disease, such as tachycardia, tachypnea,
lower extremity edema, and dyspnea, are nonspecific because they
also occur during normal pregnancy.
Risk factors associated with the development of thromboembolic
disease in the antenatal period are listed in Table
104-1. Cesarean delivery and postpartum complications further increase
the risk of developing a thromboembolism.
104-1 Risk Factors for Thromboembolic Disease in Pregnancy |Favorite Table|Download (.pdf)
104-1 Risk Factors for Thromboembolic Disease in Pregnancy
|Advanced maternal age|
|Assisted reproduction with ovarian hyperstimulation|
|Factor V Leiden mutation, |
|Protein C deficiency|
|Protein S deficiency|
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