Phlegmasia cerulea dolens...remember me?

[erinto]

Very interesting case, lesson in when to stop looking.
28 yo white female, G2, P2, three weeks post partum.    She had developed pelvic pain one week post delivery, and then her right leg became uncomfortable.   She denied pain, but noted some swelling, and a "blue hue" to the leg.    Mother had a post partum DVT, but no hypercoagulable studies have been completed.  She denies fever, SOB, chest pain, and injury.   Exam is normal, except her right leg, which was discolored, similar to this picture below.   Doppler US was completed with the following reading.  

Venous lower duplex single right 
Right: lower extremity deep veins are compressible with absent spectral doppler waveforms; superficial veins are compressible without intraluminal content. Rouleaux flow noted in common femoral, femoral and popliteal veins.
Left: common femoral vein with spontaneous phasic spectral doppler waveforms and good augmentation.
Conclusions: right: NO EVIDENCE of DVT of the lower extremity, Rouleaux formation noted in common femoral, femoral and popliteal veins.
left: NO EVIDENCE of DVT of the common femoral vein

What is your next step, given this US reading?

[pbruss]

interesting. i would be concerned with a clot in the venous structures in the pelvis. id do cta abd pelvis.

[erinto]

Thank you Dr. Bruss...

We actually consulted vascular, to get an opinion, as I thought that was the appropriate course. The CTA showed bilateral acute DVT's of the common iliac, R > L, and internal iliacs. The right common femoral and femoral veins were not excluded, and were noted to be dilated, although no clots were noted.

IR did tPA to the clots, due to their extensive nature and position. She also had a coagulopathy work up, she was heterozygous for factor V leiden and for prothrombin. She was started on coumadin, but switched to eliquis, as the clots were not felt to be responding to the coumadin.

She did well on Eliquis and was sent home on day three.