A 28-year-old woman, gravida 2 para 1, at 18 weeks gestation comes to the office for a routine prenatal appointment. She is feeling well and has had no complications during this pregnancy. The patient has no chronic medical conditions and has had no previous surgeries. Her only medications are a daily prenatal vitamin and an iron supplement. Blood pressure is 110/70 mm Hg and pulse is 62/min. BMI is 24 kg/m². Cardiopulmonary examination is unremarkable. The uterus is consistent with 18 weeks gestation and fetal heart tones are normal. There is mild bilateral pedal edema to the shins. Compared to a nonpregnant state, which of the following changes are most likely expected in this patient?

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11ec160b_3cd9_c9d9_9249_4908592797c0_MD0001_00 Normal pregnancy is associated with physiologic changes to the maternal clotting system in order to adapt to pregnancy and prepare for delivery. In general, pregnancy is a mild prothrombotic state due to the following: Increased procoagulant factors: coagulation factors involved in the intrinsic (eg, factor XII), extrinsic (eg, factor VII), and final common (eg, fibrinogen) pathways of clotting are increased by up to 200%, which promotes the formation of cross-linked fibrin clots. Decreased anticoagulant factors: protein S levels decrease and resistance to activated protein C increases, leading to reduced clotting factor proteolysis. Reduced fibrinolysis: activity of fibrinolytic inhibitors (eg, plasminogen activator inhibitor-1 derived from the placenta) increases significantly, which reduces the breakdown of fibrin clots. Although these changes protect against excessive maternal bleeding during fetal delivery and separation of the placenta, they also increase the risk of peripartum venous thromboembolism. Educational objective: Pregnancy is a prothrombotic state due to increased procoagulant factors (eg, fibrinogen), decreased anticoagulant factors (eg, protein S), and reduced fibrinolysis. These physiologic changes protect against maternal hemorrhage with delivery but increase the risk of peripartum venous thromboembolism. __________ References: Deep venous thrombosis in pregnancy: incidence, pathogenesis and endovascular management. (http://www.ncbi.nlm.nih.gov/pubmed/29399535)

A 28-Year-Old Woman, Gravida 2 Para 1, at 18 Weeks