Navigating Postpartum Venous Thromboembolism: A Case of Thrombophilia, Bleeding Complications, and Chronic Inferior Vena Cava Syndrome

Postpartum venous thromboembolism (VTE), encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE), is a critical complication occurring in the postpartum period. The pathogenesis involves a hypercoagulable state induced by pregnancy-related physiological changes, venous stasis from reduced mobility and pelvic compression during delivery, and endothelial injury. Postpartum VTE is a leading cause of maternal morbidity and mortality, necessitating heightened clinical vigilance. Understanding the risk factors, implementing prophylactic measures, and ensuring timely intervention are paramount for improving maternal health outcomes related to venous embolic events. The presented case is a 37-year-old female with a complex medical history marked by recurrent thrombotic events and pregnancy complications. Despite various prophylactic and therapeutic interventions, her condition culminated in severe chronic venous obstruction (CVO) requiring advanced interventional treatment and stent-graft implantation. Her medical history began in 2012 with two spontaneous abortions, leading to the identification of genetic mutations, including a homozygous methylenetetrahydrofolate reductase (MTHFR) mutation. In 2016, she developed PE after receiving hormonal contraceptive therapy without antithrombotic prophylaxis. Subsequent pregnancy was closely monitored, yet she suffered severe complications, including a cesarean delivery complicated by preeclampsia and postoperative thrombocytopenia, leading to massive iliofemoral-popliteal DVT. Initial treatment with vitamin K antagonists (VKA) was replaced with apixaban following a recurrent thrombotic event. Despite optimal anticoagulation, the patient developed symptomatic inferior vena cava (IVC) syndrome in 2022, characterized by chronic IVC occlusion, acute thrombosis of the portal and inferior mesenteric veins, and extensive collateral venous networks. She underwent recanalization and stenting of the iliac veins and IVC. This was followed by a hysterectomy due to metrorrhagia, significantly improving her quality of life. In this case, the homozygous MTHFR mutation was associated with recurrent thrombotic events and pregnancy complications. Despite multiple guidelines advising against MTHFR testing for thrombosis evaluation, the patient's management was influenced by her genetic profile and clinical history. Direct oral anticoagulants (DOACs) have shown efficacy in treating VTE in patients with hereditary thrombophilia. The clinical case also highlights the complexity of anticoagulation management, particularly after venous stenting, where maintaining stent patency poses significant challenges. Venous stenting, especially in CVO, has demonstrated substantial benefits, as evidenced by the patient's marked symptom improvement post-procedure. The long-term efficacy of stenting, optimal anticoagulation strategies, and post-procedural therapy require further research. This case highlights the complexities of managing hereditary thrombophilia with recurrent thrombosis and the evolving role of venous stenting in treating CVO. Individualized anticoagulation and multidisciplinary care are essential, with further studies needed to refine treatment and improve outcomes.