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Alexander, Annkay

Edwards, Wade

Ibrahim, Farrah

Olsen, Amber

English

UAB Digital Commons (Univ. of Alabama at Birmingham)

May Thurner Syndrome in PregnancyAnn Kay Alexander, BS; Amber Olsen, DO; Wade Edwards, MD; Farrah Ibrahim, MDDepartment of Family Medicine, University of Alabama at Birmingham,                          Huntsville Regional Campus ReferencesCase ReportIntroduction DiscussionA case of May Thurner Syndrome presenting acutely in the setting of pregnancy. ● A 26-year-old G3P0111 female at 9 weeks gestational age by last menstrual period presented to the OBED with 3 days of pain in her left leg. ● Patient reported 8/10 pain, radiating from groin to thigh.● Pregnancy has been uncomplicated besides symptomatic cholelithiasis managed conservatively with analgesia and bedrest, deferring cholecystectomy to post-partum. ● On physical exam, significant pain was elicited with light palpation of the left groin, leg, and knee. ● Additionally, a palpable cord-like mass was present from the left groin to just proximal to the posterior knee. Lower extremity pulses were intact bilaterally. ● On ultrasound, an extensive deep vein thrombosis was identified from the left common femoral vein to the popliteal vein. ● The patient was started on Enoxaparin 1mg/kg BID. ● Due to the significance of the clot burden, hematology was consulted ● Hematology suspected that the DVT was a result of the hypercoagulable state of pregnancy coupled with the decrease in mobility due to bed rest. ● On day 2 of hospitalization, Interventional Radiology performed an ultrasound guided endovascular mechanical thrombectomy of the left popliteal, common femoral, external iliac, and common iliac veins ● Resolution was confirmed by intravascular ultrasound. ● On day 4, the patient began to experience increasing pain in the left lower extremity.● Recurrence of the popliteal thrombosis was found on ultrasound. ● On day 5, a repeat thrombectomy of the femoral and popliteal veins was completed.● Confirmation of resolution was again completed via intravascular ultrasound● Patient was discharged on day 7 with enoxaparin and recommendations for compression stockings and ambulation. ● Approximately three weeks following initial hospitalization, the patient presented with one day of recurring left lower extremity pain. ● She reported that she had been unable to fill her enoxaparin prescription one week prior due to cost of the medication. ● Patient was again found to have a DVT in the femoral and popliteal veins via ultrasound. ● IR was consulted and took the patient for thrombectomy with the addition of stent placement. ● At the time of this procedure, it was noted that there was evidence of May Thurner compression. ● Post-partum venogram for MTS was suggested. ● On day 3 of hospitalization, the patient was discharged home with an enoxaparin prescription.● The physiologic changes of pregnancy include a hypercoagulable state.● Patients with multiple episodes of DVT should be evaluated for underlying etiologies● May Thurner syndrome may initially present in the setting of pregnancy with DVT as primary presenting sign. ● May Thurner Syndrome (MTS) is external compression of venous flow by a nearby arterial vessel. ● MTS most commonly occurs when flow through the left common iliac vein is compromised by the right common iliac artery. ● MTS commonly presents as extensive DVT in patients who are post-partum, multiparous, or using oral contraceptives. ● Catheter directed thrombolysis should be used in the setting of extensive DVT. ● CT or MR venography can be used to evaluate MTS in the absence of venous thrombosis. Intravascular ultrasound is required for definitive diagnosis. ● DVT is often treated supportively with heparin and compression during pregnancy, however percutaneous therapy should be considered in extensive DVT due to underlying MTS. Figure 1D'Souza, Donna. “May-Thurner Syndrome: Radiology Reference Article.” Radiopaedia Blog RSS, radiopaedia.org/articles/may-thurner-syndrome-2?lang=us. May R, Thurner J. The cause of the predominantly sinistral occurrence of thrombosis of the pelvic veins. Angiology. 1957 Oct;8(5):419-27. doi: 10.1177/000331975700800505. PMID: 13478912.Kibbe MR, Ujiki M, Goodwin AL, Eskandari M, Yao J, Matsumura J. Iliac vein compression in an asymptomatic patient population. J Vasc Surg. 2004 May;39(5):937-43. doi: 10.1016/j.jvs.2003.12.032. PMID: 15111841.Wax JR, Pinette MG, Rausch D, Cartin A. May-Thurner syndrome complicating pregnancy: a report of four cases. J Reprod Med. 2014 May-Jun;59(5-6):333-6. PMID: 24937979.

May Thurner Syndrome in Pregnancy

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May Thurner Syndrome in Pregnancy

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