Inflammatory bowel disease (IBD) is a risk factor for thrombotic complications, using multifactorial mechanisms such as platelet activation, increased fibrinogen, and coagulation factors 2, 5, 7, 8, 10, and 11 and destruction of endothelial function. Pregnancy is a risk factor to increase coagulation in patients due to the change in procoagulation factors in the hemostatic system and the reduction in anti-coagulation factors such as protein C, S; especially, the increased risk of coagulation in the pelvic vessels happens due to the rise in blood pressure.3 Therefore, pregnancy is a risk factor in developing venous thromboembolism (VTE), including DVT and PTE. Although pregnant patients with IBD are at risk of increased hyper coagulate state, it is a known leading cause of maternal mortality. The risk of increased coagulation in pregnant patients with IBD is high, but happening in the CNS vessels is rare and severe. Around 1% of patients suffer from thrombosis of the CNS vessels. Although the patients usually have symptoms such as seizures, headaches, variable levels of unconsciousness, and papillary edema, these patients are typically diagnosed late and have a poor prognosis.
A 35-year-old Iranian woman, G3Ab2, presented due to intrauterine growth restriction (IUGR) and disappearance of the end-diastolic wave of the umbilical artery in the sonography. She was at 32 weeks, and an emergency cesarean section was done. She had ulcerative colitis for 15 years. Her disease flared up during pregnancy. Her colonoscopy demonstrated an ulcerative colitis diagnosis. She has been treated with mesalazine, aspirin, and enoxaparin since the beginning of pregnancy.
Two months after delivery, the patient presented with cough, shortness of breath, mild respiratory distress, headache, fever, myalgia, tachycardia, and right leg pain. The patient mentioned that her headache has gradually increased since childbirth. The patient's neurological examination was normal. The patient's EKG (electrocardiography) was normal without any pathological findings. But in her laboratory tests, a positive D-dimmer was reported. Her laboratory test revealed: platelet: 135000/mm3, PT: 13 s, PTT: 26 s, and INR: 1.1. The thrombophilia screening test was done, and the test result was negative. Arterial and venous color Doppler ultrasound of both lower limbs was performed, and no evidence of thrombosis or obstruction was observed. In the abdomen ultrasound, a cyst without septa and a solid component, size 27 × 28 mm, was observed in the right ovary. Her chest X-ray was normal. CT angiography reported a partial filling defect in the arteries of the inferior lobe in the right lung. The diagnosis of pulmonary embolism (PE) in the inferior lobe of the right lung was confirmed, provided by CT angiography. CT scan of the patient's brain had hyperdensity in the left occipital lobe. Her brain MRV imaging revealed a lack of flow-related enhancement, which was suspicious for venous thrombosis. Her brain MRI showed abnormal signal changes at the left temporal lobe related to intraparenchymal hemorrhage accompanied by mild edema. The patient was transferred to the intensive care unit (ICU). She was diagnosed with PTE and sinus thrombosis simultaneously. She was treated with anticoagulant drugs such as heparin and warfarin. The patient was treated with the anticonvulsant drug and was discharged after a week. After 2 months, she went to the hospital with abdominal pain extending to the shoulder. The next day she had a laparotomy for a hemorrhagic cyst. During the surgery, the third space had 3.5 liters of blood. Because her INR was around 4, until 4 days after the surgery, heparin was replaced with warfarin. After 2 days, her INR reached approximately 2.5. Then, warfarin was started, and heparin was stopped. Finally, the patient was discharged in good general condition.
