bs_bs_banner
Internal Medicine Journal 45 (2015)
L E T T E R S TO T H E E D I TO R
Clinical-scientific notes Isolated iliac vein thrombosis in pregnancy Isolated iliac vein thrombosis of the left leg is an uncommon phenomenon but occurs more frequently in pregnancy.1 This case illustrates the utility of magnetic resonance venography (MRV) in assessing the iliac vessels when a pregnant woman presents with a high clinical suspicion for deep vein thrombosis (DVT), but in whom routine compression ultrasonography was unable to diagnose the thrombus. A 44-year-old woman at 29 weeks gestation of her first pregnancy presented with a 3-day history of left leg pain and swelling. This was her fourth and only successful in vitro fertilisation pregnancy following a history of unexplained infertility. This particular in vitro fertilisation cycle involved a frozen embryo transfer using a donor egg and was supported by ongoing progesterone supplementation in the form of pessaries. Clinical examination showed a swollen leg with a left calf diameter 4 cm greater than the right. Her D-dimer was elevated at 0.76 mg/L (0.00–0.20 mg/L). While an external and repeat compression ultrasound showed normal compressibility of the proximal leg veins, there was loss of normal phasic variation in flow in the distal left external iliac vein. The common iliac and proximal external iliac vein could not be visualised appropriately for Doppler imaging due to the gravid uterus. MRV was performed to obtain angiographic type images. A proximal filling defect within the left common iliac vein was confirmed (Figs 1,2) compared with an intense signal representing normal blood flow in the right common iliac vein (Fig. 1). The patient was commenced on therapeutic anticoagulation with enoxaparin 1 mg/Kg twice daily (i.e. 70 mg twice daily as the admission weight was 70 Kg), which was continued until she delivered a healthy newborn at 39 weeks. Pre- and immediate post-delivery anticoagulation was switched to a low-dose heparin infusion prior to re-initiation of enoxaparin at 48 h, gradually reaching therapeutic doses over the subsequent few days. Unfortunately, despite the cautious post-partum re-anticoagulation, she presented 9 days later with a major delayed post-partum haemorrhage secondary to retained products requiring a curettage and blood transfusion. Enoxaparin was safely reintroduced at a lower dose and continued for a further 6 weeks. Radiological options for diagnosis of isolated iliac vein thrombosis include ultrasound, contrast venography,
Figure 1 Axial plane.
Figure 2 Sagittal plane. Figures 1 and 2 are MRV images of left iliac veins acquired with a 1.5 T Siemens Avanto scanner and a torso coil (Siemens Medical Solutions, Erlangen, Germany) using a 2D time of flight FLASH acquisition with flow compensation. Figure 1 (axial plane) shows the thrombus within the left common iliac vein (right arrow) where there is dark material shown within the vein compared with the bright signal in the unobstructed normal right common iliac vein (left arrow). Figure 2 shows the same filling defect in the sagittal plane.
computer-assisted tomography venography and MRV, as utilised in this case. Ultrasound Doppler assessment of iliac vessels, if possible, may show an echogenic thrombus or absent flow in this vessel, which would be sufficient to make a diagnosis of isolated iliac vein thrombosis. If this and serial compression ultrasound are non-diagnostic or feasible due to the © 2015 Royal Australasian College of Physicians
460
bs_bs_banner
Letters to the Editor
deep location of the veins being interrogated, as was the predicament in this case, additional investigation is necessary.2 Carefully performed contrast venography, with pelvic shielding is useful and can be performed safely with acceptable radiation exposure to the foetus (less than 0.5 mSv with shielding and 3.1 mSv without shielding).3 On the other hand, as this test is not readily performed, appropriately skilled staff and equipment may not be easily available. Computer-assisted tomography venography while useful outside of pregnancy is associated with high levels of ionising radiation exposure to the foetus. However, MRV, as exemplified here, can be used to produce images of the iliac veins, does not involve radiation exposure to the foetus and can avoid the use of gadolinium chelates that cross the placental barrier. In this scenario, we did not use a conventional 2D or 3D time of flight MRV acquisition, which can be prone to flow arte-
References
Received: 12 August 2014; Accepted 11 January 2015. doi:10.1111/imj.12718 1
C. B. Keragala, K. D. Cummins,1 S. K. Goergen,2,3 D. Shipp2 and S. Chunilal1,4 1
Monash Haematology Haemostasis and Thrombosis Unit, Monash Medical Centre, Monash Health, 2Monash Imaging, Monash Health, Monash Medical Centre, 3Department of Surgery, Southern Clinical School and 4Department of Haematology, Monash University, Melbourne, Victoria, Australia
et al. Recommendations for the diagnosis and treatment of deep venous thrombosis and pulmonary embolism in pregnancy and the postpartum period. Aust N Z J Obstet Gynaecol 2012; 52: 14–22.
1 Bates SM, Ginsberg JS. How we manage venous thromboembolism during pregnancy. Blood 2002; 100: 3470–8. 2 McLintock C, Brighton T, Chunilal S, Dekker G, McDonnell N, McRae S
‘Avoidable’ death of a pregnant Jehovah’s Witness with acute promyelocytic leukaemia: ethical considerations and the internal conflicts and challenges encountered by practitioners A 28-year-old woman was transferred to our hospital at 27 + 6/40, G5P2, with pre-eclampsia. Acute promyelocytic leukaemia (APL) with disseminated intravascular coagulation was diagnosed (Table 1). Table 1 Pathology results during admission
Haemoglobin (g/L) Platelets (×109/L) INR APTT (25–37 s) Fibrinogen (g/L) D dimer (μg/mL) LDH (U/L) Creatinine (μmol/L)
facts mimicking thrombus. Instead, a combination of black blood (HASTE) and bright blood (True FISP) sequences were used to depict the absence of signal from flowing blood (which is normally dark on HASTE and bright on True FISP). In this unique clinical situation, MRV proved to be an accurate, safe and reliable diagnostic tool.
Day 1
Day 3
Day 5
Day 8
Day 11
Day 13
105 21 1.2 24 1.3 >20 721 73
93 23 1.3 27 0.8 >20 977 100
90 25 1.2 28 1.2 18 1711 157
80 28 1.2 28.5 1.5 16 2133 189
46 21 1.9 34 2.7 >20 2700 294
48 17 1.3 24 — — — 282
APTT, activated partial thromboplastin time; INR, international normalised ratio; LDH, lactate dehydrogenase.
3 Ginsberg JS, Hirsh J, Rainbow AJ, Coates G. Risks to the fetus of radiologic procedures used in the diagnosis of maternal venous thromboembolic disease. Thromb Haemost 1989; 61: 189–96.
The patient was a Jehovah’s Witness with an advanced care directive refusing the transfusion of red cells, white cells, platelets or plasma, and all minor fractions including albumin, immunoglobulins and clotting factors. She continued to refuse blood products, despite understanding the circumstance-specific consequences, including death. Antihypertensives, prednisone and all-trans-retinoic acid were commenced. Chemotherapy was deemed unsafe in the setting of upcoming delivery without blood product support. Foetal death in utero was followed by vaginal delivery with minimal blood loss. Subsequently, the patient developed an ischaemic stroke, febrile neutropenia and multi-organ failure. Treatment was withdrawn on day 13. Staff were distressed, grappling with what was perceived as two ‘avoidable’ deaths. APL has a >90% cure rate. In pregnancy, complete remission rates of 83% are reported, and foetal outcomes are reasonable when diagnosis occurs in the second or third trimesters.1 Good outcomes are also reported in the case of a Jehovah’s Witness declining blood products.2 We document this poor outcome to assist other health professionals in providing balanced information to patients in this circumstance, to explore the ethical considerations
© 2015 Royal Australasian College of Physicians
461
Copyright of Internal Medicine Journal is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Internal Medicine Journal 45 (2015)
L E T T E R S TO T H E E D I TO R
Clinical-scientific notes Isolated iliac vein thrombosis in pregnancy Isolated iliac vein thrombosis of the left leg is an uncommon phenomenon but occurs more frequently in pregnancy.1 This case illustrates the utility of magnetic resonance venography (MRV) in assessing the iliac vessels when a pregnant woman presents with a high clinical suspicion for deep vein thrombosis (DVT), but in whom routine compression ultrasonography was unable to diagnose the thrombus. A 44-year-old woman at 29 weeks gestation of her first pregnancy presented with a 3-day history of left leg pain and swelling. This was her fourth and only successful in vitro fertilisation pregnancy following a history of unexplained infertility. This particular in vitro fertilisation cycle involved a frozen embryo transfer using a donor egg and was supported by ongoing progesterone supplementation in the form of pessaries. Clinical examination showed a swollen leg with a left calf diameter 4 cm greater than the right. Her D-dimer was elevated at 0.76 mg/L (0.00–0.20 mg/L). While an external and repeat compression ultrasound showed normal compressibility of the proximal leg veins, there was loss of normal phasic variation in flow in the distal left external iliac vein. The common iliac and proximal external iliac vein could not be visualised appropriately for Doppler imaging due to the gravid uterus. MRV was performed to obtain angiographic type images. A proximal filling defect within the left common iliac vein was confirmed (Figs 1,2) compared with an intense signal representing normal blood flow in the right common iliac vein (Fig. 1). The patient was commenced on therapeutic anticoagulation with enoxaparin 1 mg/Kg twice daily (i.e. 70 mg twice daily as the admission weight was 70 Kg), which was continued until she delivered a healthy newborn at 39 weeks. Pre- and immediate post-delivery anticoagulation was switched to a low-dose heparin infusion prior to re-initiation of enoxaparin at 48 h, gradually reaching therapeutic doses over the subsequent few days. Unfortunately, despite the cautious post-partum re-anticoagulation, she presented 9 days later with a major delayed post-partum haemorrhage secondary to retained products requiring a curettage and blood transfusion. Enoxaparin was safely reintroduced at a lower dose and continued for a further 6 weeks. Radiological options for diagnosis of isolated iliac vein thrombosis include ultrasound, contrast venography,
Figure 1 Axial plane.
Figure 2 Sagittal plane. Figures 1 and 2 are MRV images of left iliac veins acquired with a 1.5 T Siemens Avanto scanner and a torso coil (Siemens Medical Solutions, Erlangen, Germany) using a 2D time of flight FLASH acquisition with flow compensation. Figure 1 (axial plane) shows the thrombus within the left common iliac vein (right arrow) where there is dark material shown within the vein compared with the bright signal in the unobstructed normal right common iliac vein (left arrow). Figure 2 shows the same filling defect in the sagittal plane.
computer-assisted tomography venography and MRV, as utilised in this case. Ultrasound Doppler assessment of iliac vessels, if possible, may show an echogenic thrombus or absent flow in this vessel, which would be sufficient to make a diagnosis of isolated iliac vein thrombosis. If this and serial compression ultrasound are non-diagnostic or feasible due to the © 2015 Royal Australasian College of Physicians
460
bs_bs_banner
Letters to the Editor
deep location of the veins being interrogated, as was the predicament in this case, additional investigation is necessary.2 Carefully performed contrast venography, with pelvic shielding is useful and can be performed safely with acceptable radiation exposure to the foetus (less than 0.5 mSv with shielding and 3.1 mSv without shielding).3 On the other hand, as this test is not readily performed, appropriately skilled staff and equipment may not be easily available. Computer-assisted tomography venography while useful outside of pregnancy is associated with high levels of ionising radiation exposure to the foetus. However, MRV, as exemplified here, can be used to produce images of the iliac veins, does not involve radiation exposure to the foetus and can avoid the use of gadolinium chelates that cross the placental barrier. In this scenario, we did not use a conventional 2D or 3D time of flight MRV acquisition, which can be prone to flow arte-
References
Received: 12 August 2014; Accepted 11 January 2015. doi:10.1111/imj.12718 1
C. B. Keragala, K. D. Cummins,1 S. K. Goergen,2,3 D. Shipp2 and S. Chunilal1,4 1
Monash Haematology Haemostasis and Thrombosis Unit, Monash Medical Centre, Monash Health, 2Monash Imaging, Monash Health, Monash Medical Centre, 3Department of Surgery, Southern Clinical School and 4Department of Haematology, Monash University, Melbourne, Victoria, Australia
et al. Recommendations for the diagnosis and treatment of deep venous thrombosis and pulmonary embolism in pregnancy and the postpartum period. Aust N Z J Obstet Gynaecol 2012; 52: 14–22.
1 Bates SM, Ginsberg JS. How we manage venous thromboembolism during pregnancy. Blood 2002; 100: 3470–8. 2 McLintock C, Brighton T, Chunilal S, Dekker G, McDonnell N, McRae S
‘Avoidable’ death of a pregnant Jehovah’s Witness with acute promyelocytic leukaemia: ethical considerations and the internal conflicts and challenges encountered by practitioners A 28-year-old woman was transferred to our hospital at 27 + 6/40, G5P2, with pre-eclampsia. Acute promyelocytic leukaemia (APL) with disseminated intravascular coagulation was diagnosed (Table 1). Table 1 Pathology results during admission
Haemoglobin (g/L) Platelets (×109/L) INR APTT (25–37 s) Fibrinogen (g/L) D dimer (μg/mL) LDH (U/L) Creatinine (μmol/L)
facts mimicking thrombus. Instead, a combination of black blood (HASTE) and bright blood (True FISP) sequences were used to depict the absence of signal from flowing blood (which is normally dark on HASTE and bright on True FISP). In this unique clinical situation, MRV proved to be an accurate, safe and reliable diagnostic tool.
Day 1
Day 3
Day 5
Day 8
Day 11
Day 13
105 21 1.2 24 1.3 >20 721 73
93 23 1.3 27 0.8 >20 977 100
90 25 1.2 28 1.2 18 1711 157
80 28 1.2 28.5 1.5 16 2133 189
46 21 1.9 34 2.7 >20 2700 294
48 17 1.3 24 — — — 282
APTT, activated partial thromboplastin time; INR, international normalised ratio; LDH, lactate dehydrogenase.
3 Ginsberg JS, Hirsh J, Rainbow AJ, Coates G. Risks to the fetus of radiologic procedures used in the diagnosis of maternal venous thromboembolic disease. Thromb Haemost 1989; 61: 189–96.
The patient was a Jehovah’s Witness with an advanced care directive refusing the transfusion of red cells, white cells, platelets or plasma, and all minor fractions including albumin, immunoglobulins and clotting factors. She continued to refuse blood products, despite understanding the circumstance-specific consequences, including death. Antihypertensives, prednisone and all-trans-retinoic acid were commenced. Chemotherapy was deemed unsafe in the setting of upcoming delivery without blood product support. Foetal death in utero was followed by vaginal delivery with minimal blood loss. Subsequently, the patient developed an ischaemic stroke, febrile neutropenia and multi-organ failure. Treatment was withdrawn on day 13. Staff were distressed, grappling with what was perceived as two ‘avoidable’ deaths. APL has a >90% cure rate. In pregnancy, complete remission rates of 83% are reported, and foetal outcomes are reasonable when diagnosis occurs in the second or third trimesters.1 Good outcomes are also reported in the case of a Jehovah’s Witness declining blood products.2 We document this poor outcome to assist other health professionals in providing balanced information to patients in this circumstance, to explore the ethical considerations
© 2015 Royal Australasian College of Physicians
461
Copyright of Internal Medicine Journal is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
