Case presentation

37 years old Iranian female, a known case of hypothyroidism and class III obesity, admitted to our hospital for laparoscopic gastric sleeve surgery (150 cm, 95 kg, and BMI: 42.2 kg/m2). She had a previous surgical history of three caesarian sections; the last one was almost 7 years earlier than this admission. She was on levothyroxine and metformin (self-prescribed in order to lose weight) and did not use birth control. She had no family history of inheritable coagulopathies, and her social history was unremarkable.
Laboratory and clinical pre-operative evaluations were unremarkable, including anesthesia, endocrinology, and cardiology. For thromboprophylaxis, compression stockings were applied, and she received a single dose (5000 IU) of subcutaneous heparin one hour before the surgery, according to the local guidelines. Her operation was uneventful, and sleeve gastrectomy was conducted in 100 minutes with six 60 mm purple endostaplers. At the end of the surgery, a Jackson-Pratt (JP) drain was inserted at the surgery site. She recovered, returned to the ward, and prophylactic enoxaparin (60 mg/day subcutaneously) started within 6 hours after surgery. The patient was ambulated as soon as she became conscious and hemodynamically stable. The first post-operative night was uneventful, but she fainted the next morning after ambulation. She was tachycardic (pulse rate 140 bpm) and hypotensive (systolic blood pressure 80 mmHg). JP drain did not contain bloody discharge. After primary resuscitation, considering myocardial infarction, anastomotic leakage, and PE as top differential diagnoses, the following evaluations were initiated: