Occult Iliac Deep Vein Thrombosis in Second Trimester Pregnancy: Clues on Bedside Ultrasound

Abstract

Isolated pelvic deep vein thromboses (DVT) are rare and difficult to diagnose, but they are more common in pregnant women and carry an increased risk of embolization. Pulmonary embolism is the most common non-obstetric cause of death in pregnancy. Compression ultrasound is the first-line imaging test for suspected lower extremity DVT, but it cannot usually aid in directly visualizing or easily diagnosing isolated pelvic DVT. Nonetheless, point-of-care ultrasound (POCUS) may provide valuable clues to help rule in pelvic DVT and expedite initiation of anticoagulant therapy. Such findings include increased venous diameter, increased resistance to compression, visible venous reflux, and blunted phasicity. This case presents an example of how these findings on POCUS led the emergency physician to make the difficult diagnosis of pelvic DVT at the bedside within seconds.

Point‐of‐care ultrasound in obstetrics

“…There are a significant number of case reports in the literature, which describe the use of PoCUS in exceptional circumstances. Examples of this include the diagnosis of uterine rupture, cervical ectopics, DVTs and pulmonary oedema associated with pre‐eclampsia, and fetal abnormalities and abnormal dopplers . This can be misleading as it suggests that clinician in the emergency or outpatient settings will be able to make these diagnoses themselves.…”

A Call for Development of Point‐of‐Care Ultrasound Training Recommendations in Obstetrics and Gynecology Residency

“…24,25 Urgent identification of pulmonary edema in patients with preeclampsia, peripartum dyspnea, deep vein thrombosis, or pulmonary vascular emergency can be incredibly challenging; POCUS improves diagnostic accuracy for each of these conditions. 26,27 Training in the use of POCUS during Ob/Gyn residency is critical, but has not received the attention directed to other specialties. Notably, prior to residency, POCUS training has been widely adopted amongst a majority of medical schools.…”

“…Diagnostically, abdominal pain in pregnancy has a broad differential that can be quickly narrowed by POCUS to allow for rapid diagnosis and triage of the patient, whether the etiology is ruptured ectopic pregnancy, pelvic abscesses, or hemorrhage 24,25 . Urgent identification of pulmonary edema in patients with preeclampsia, peripartum dyspnea, deep vein thrombosis, or pulmonary vascular emergency can be incredibly challenging; POCUS improves diagnostic accuracy for each of these conditions 26,27 …”