Deep Vein Thrombosis: A case report
Parimala
Clinical Instructor, Kauvery Hospital, Chennai, Tamilnadu, India.
*Correspondence: nursingdirector.kch@kauveryhospital.com
Abstract
Deep vein thrombosis (DVT) is an obstructive/occlusive disease that hinders venous drainage It usually involves the lower limb venous system, and involves clot formation that originates in deep calf veins. Venous thrombosis occurs in areas with decreased or mechanically altered blood flow such as at the vicinity of valves in the deep veins of the legs and causes venous stasis and hypoxia.
The mechanisms underlying deep venous thrombosis is interaction between inflammation and hemostasis. It has been described that the alteration of venous blood flow produces endothelial activation, adhesion of platelets and contribute to the activation of coagulation.
Virchow’s Triad, was established in 1856, and implicates three contributing factors in the formation of thrombosis: stasis of flow, vascular injury, and hypercoagulability.
Deep venous thrombosis is commonly triggered by the interaction between acquired risk factors, such as hip fracture, surgery or trauma, malignancy, pregnancy, immobility, obesity, advancing age and hereditary conditions. The cardinal signs and symptoms of DVT include asymmetrical swelling, warmth, and pain in an extremity and venous ulcers.
Background
Deep vein thrombosis (DVT), a subset of venous thromboembolism (VTE), is a major preventable cause of morbidity and mortality worldwide. The prevalence of VTE is estimated to be 1 per 1,000 people affecting with DVT annually.
National center for Biotechnology Information, 2022 stated that DVT affects more than 200,000 people in the United States in which 50,000 cases are complicated by pulmonary embolism.
In a prospective study to assess the prevalence of risk factors for venous thromboembolism among pregnant women in Hyderabad, Telangana, India. 200 antenatal and postnatal were included in the study by using a pragmatic approach.The study concluded that 20% of pregnant women had intermediate risk factors (immobility, Ovarian hyperstimulation syndrome (OHSS), medical comorbidities, and surgical procedures) and 20% had low-risk factors. Approximately 80 women (40%) had significant risk factors for the development of VTE during pregnancy and postpartum period.
Case presentation
A 30 years-aged- female patient was admitted with the complaints of left lower limb swelling and pain for 2 days. She had undergone LSCS one month earlier. On physical examination there was edema and redness from the groin region to left lower limb and in addition there was calf muscle tenderness.
There was elevated D-dimer and fibrinogen levels in the blood.
In CT venogram, hypoechoic thrombus was found in the common femoral vein and it was extending into the external iliac, common iliac up to the infrarenal IVC, with no flow.
Hence the patient was diagnosed with Post-Partum DVT (Left iliofemoral DVT with IVC extension and right CIV extension).
A surgical procedure, IVC filter deployment and angioget PMT was planned and done. Post operatively she was under treatment of Heparin and Altepase infusion and during discharge she was advised with LMWH and other supportive measures. Patient’s condition improved symptomatically and clinically stable.
On clinical assessment
Temperature |
Pulse |
Respiration |
Blood pressure |
SPO2 |
| 98.6 F | 112/min | 20/min | 110/60 mmHg | 98% |
Lower Limb Examination
Right leg |
|
Left leg |
|
Investigation Reports
Date |
Investigation |
Report |
| 11/02/23 | CBC | HB-9.1 g/dl |
| WBC-14300 Cells/cumm | ||
| Platelet count 360000 Cells/cumm | ||
| ESR 30 | ||
| RFT | Urea 13.2 mg/dl | |
| Creatinine- 0.62 mg/dl | ||
| Sodium 141 mmol/L | ||
| Potassium 4.64 mmol/L | ||
| Chloride 107.5 mmol/L | ||
| Bicarbonate 18.1 mmol/L | ||
| LFT | All the parameters in normal range | |
| Homocysteine | 7.4 mol/L | |
| D-Dimer | 2690 ng/ml | |
| Fibrinogen | 366 mg/dl |
Drug Chart
Empirical treatment |
||
S.No |
Drug name |
Dose/Frequency |
| 1 | Inj.Supacef | 1.5gm/BD |
| 2 | Inj.Para | 1gm/BD |
| 3 | Inj.Clexane | 0.6ml/BD |
Surgical treatment |
||
| 1 | Inj.Heparin | 600 units/hr |
| 2 | Inj.Alteplase | 7ml/hr |
Follow up treatment |
||
| 1 | Inj.Fondared | 7.5mg/OD |
| 2 | Tab.Acitrom | 4mg /OD |
| 3 | Tab.Livogen | One/OD |
| 4 | Tb.Homochek | One /OD |
Nursing Care
- Advised the patient to avoid green leafy vegetables and extra salt in the food items.
- Advised the patient to take medications regularly
- Educated the patient to avoid putting constant pressure on the posterior region of knee.
- While sitting in a car or bus, wiggle your toes, tighten and relax the calf muscles, and shift your position often.
- Educated about personal care and hygienic measures
Discussion
The risk of pregnancy-related VTE increases due to a prothrombotic state in pregnant, blood flow stagnation, and vascular traumas during delivery, particularly with assistive devices and cesarean section.
The prevention of VTE in peripartum patients with the above-mentioned risk factors should be treated with anticoagulation therapy and it is an important standard treatment for DVT. This prevents new clot formation and reduces the risk of recurrent venous thromboembolism.
Conclusion
The risk of VTE increased during peripartum period and the best course of treatment for DVT patients is thrombectomy. This procedure has multiple benefits like, it can restore venous patency, recurrence of DVT, alleviate post-traumatic stress, and prevents pulmonary embolism.
The prevalence of DVT among pregnant women is low (3%) it has the common type of TE complications. LMWH is frequently used as a thromboprophylaxis agent.
References
- Stone, J., et al. Deep vein thrombosis: pathogenesis, diagnosis, and medical management.Cardiovasc Diagn Ther. 2017;7(Suppl 3):S276S284.
- Navarrete, S., et al.Pathophysiology of deep vein thrombosis.Clin Exp Med. 2022.
- Lu, ZX., et al. Safety and Efficacy of Endovascular Treatment on Pregnancy-Related Iliofemoral Deep Vein Thrombosis. Clin Appl Thromb/Hemost. 2022;28.
- Waheed SM, et al. Deep Vein Thrombosis. [Updated 2022 Nov 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022.
- Varre, H., et al. Prevalence of venous thromboembolism risk factors in pregnant women. Ind J Vascul Endovascul Surg. 2020;7(3):225.