Protein S deficiency causing postpartum stroke following twin delivery in a multiparous woman: a case report and review of literature

Abstract

Protein S deficiency is a thrombophilia known to cause venous thromboembolism. During pregnancy, it can present as deep vein thrombosis or adverse feto-maternal events such as stillbirth or intrauterine growth restriction. Its link to arterial thrombosis remains controversial. We report a case of a 31-year-old multiparous woman with no known comorbidities who developed acute left upper limb pain on postpartum day 20 following an uneventful twin delivery. Her condition progressed to giddiness, vomiting, seizures, and poor sensorium. Imaging studies revealed extensive ischemic infarctions involving the posterior circulation and thrombotic occlusions in the upper limb vasculature. She was managed with anticoagulation therapy, antibiotics for ventilator-associated pneumonia, and a left parieto-occipital decompressive craniotomy due to worsening sensorium. Thrombophilia workup identified isolated Protein S deficiency, while other markers of thrombophilia, including Protein C, antithrombin III, and factor V Leiden mutation, were normal. Despite complications, her sensorium improved with comprehensive management, and she was discharged on long-term anticoagulation. This case highlights the need for heightened awareness of postpartum thrombotic events in women with no antenatal complications. Protein S deficiency, though rare, should be considered in the differential diagnosis to ensure prompt and effective intervention, reducing morbidity and mortality in postpartum women.