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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

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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.

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Epidemiology

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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 year.3

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Pathophysiology

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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 stasis.

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Clinical Features

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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.

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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.

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Table Graphic Jump Location
Table 104-1 Risk Factors for Thromboembolic Disease in Pregnancy 

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