(601) A Serious Headache: Navigating Venous Sinus Thrombosis Management in the Era of Abortion Restriction

Introduction: We present a case of cerebral veinous sinus thrombosis (CVST) in a pregnant female.

Description: 23-year-old woman presented in coma after a week of frequent vomiting and severe headache. Head CT demonstrated severe cerebral edema, cerebellar hemorrhage, and obstructive hydrocephalus. CTV confirmed an extensive CVST. Also noted were bilateral pulmonary embolisms. She was emergently managed with decompressive suboccipital craniotomy, external ventricular drain placement, and anticoagulation.

Her admission pregnancy test was positive. Ultrasound confirmed an intra-uterine pregnancy of 9 weeks, past the gestation age at which a pregnancy can be legally terminated in Georgia.

An extensive workup for an underlying etiology for hypercoagulability was negative; thus, her hypercoagulability was attributed to pregnancy. Ethically and legally, further management was complicated by her inability to make an informed decision given comatose state and the restrictive abortion laws in Georgia.

The case was discussed with maternofetal medicine and the hospital’s ethics and legal committees. It was agreed that resultant hypercoagulability of pregnancy directly endangered the mother’s life. Extensive conversations were held with patient’s next of kin on their beliefs of what the patient would want in this critical situation. With next of kin consent, dilatation and curettage procedure was successfully performed.
Magnetic resonance venogram 2 days after revealed significant recanalization of the venous sinuses.

Discussion: There are ethical challenges of caring for pregnant women who lack capacity for informed consent. This has been further complicated the recent enactment of severe abortion restrictions in many states, which added significant legal hurdles to care. However, abortion is permitted if a physician determines a "medical emergency.” Since pregnancy was the most likely mechanism for thrombosis, multiple teams agreed that it constituted a direct threat to our patient’s health. Allowing for life saving treatment.

CVST is rare but life-threatening disease in pregnant women with a prevalence of 1.2 per 100,000 deliveries. Consideration of emergent abortion in these cases is paramount for maternal safety and is within the legal boundaries, even in states with the most restricted of laws.