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Our patient presents with atypical distribution of DVT. A primipara presented to our service with pain and thrombosed veins of the right calf and thight at 13 and 22 weeks of gestation.

Doppler ultrasound excluded DVT. Treatment with topical heparin and elastic support was recommended. Follow-up revealed satisfactory progress. At 34 weeks of gestation, the patient presents to our department with acute pain of her right thigh. Doppler examination confirmed DVT at this atypical site. Systemic heparin therapy and follow-up were initiated. The patient recovered uneventfully, and the fetus was delivered at term via C-section. The awareness of venous conditions during pregnancy may prevent potentialy life-threatening complications for both the mother and fetus through optimal management of high-risk patients.

Keywords thrombophlebitis, deep vein thrombosis, pregnancy Rezumat Sarcina este asociată cu o stare de hipercoagulabilitate care reprezintă un mecanism adjuvant al hemostazei, imediat post-partum. O pacientă primipară s-a adresat serviciului nostru, în trimestrul al doilea de sarcină, prezentând tromboflebită superficială recurentă şi, ulterior, în trimestrul al treilea de sarcină, prezentând TVP cu distribuţie anatomică atipică, diagnosticul fiind stabilit ultrasonografic.

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Conduita terapeutică a inclus contenţie elastică, heparină cu administrare topică şi heparină administrată sistemic. Recuperarea pacientei a fost optimă, iar fătul a fost născut la termen, prin operaţie cezariană. Atenţia îndreptată spre conduita terapeutică adecvată în cazul afecţiunilor venoase pe parcursul sarcinii poate preveni complicaţiile ameninţătoare de viaţă pentru mamă şi făt. The risk of this cosequence may be diminished with proper treatment and prophylaxis 1,2.

The procoagulant changes are physiologic and considered to be preparatory measures for the hemostatic challenge of delivery.

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The risk of thrombotic events increases moreover up to 6 weeks after delivery, probably because of the endothelial damage to the pelvic vessels that occurs during delivery 6but there is evidence indicating that an increased risk persists up to 12 weeks after delivery 7. Venous thrombosis is a multi-causal disease; a previous pregnancy-related venous thrombosis, a high Body Mass Index, hyperemesis leading to dehydration and immobilitythrombophilias and tobacco use are among the strongest risk factors for this condition.

Little data is great saphenous vein removal from randomized trials involving pregnant women to guide the prophilaxy, diagnosis and treatment of uncomplicated superficial or deep venous thrombosis in pregnancy; the management tools and decision-making strategies are mostly derived from observational studies, trials involving non-pregnant patients or trials involving pulmonary thrombembolism PTE.

The diagnosis of thrombosis in pregnancy must include both clinical examination tencuiala de la varicoze fy imaging diagnosis tools. Clinical examination would be insufficient to diagnose thrombosis in pregnancy because specific signs and symptoms - such as lower extremity edema, dyspnea and mild tachycardia - are frequently inaccurate and difficult to differentiate from the physiologic changes of pregnancy.

Since the risk of DVT and venous thromboembolism VTE is increased during pregnancy and postpartum, and morbidity and mortality are considerable, a low threshold for further testing great saphenous vein removal recommended. The current initial test of choice to assess suspicion of deep-vein thrombosis is compression duplex ultrasonographic examination, including the evaluation of the ilio-femoral region 12, A study of single compression Doppler ultrasonographic examination involving more than pregnant and postpartum women indicated that this test was a very reliable screening test hence can safely rule out the diagnosis of deep-vein thrombosis If the test reveals a negative result and the clinical suspicion of DVT remains high, it may be judicious to repeat the test after days.

It would also be safe to withold anticoagulation while waiting to repeat the test cum se aplica sifon în varicoza If the result of compression Doppler ultrasound is negative and there is no suspicion of DVT, the patient may return to routine observation.

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Otherwise, if there is a discordance between clinical presentation and ultrasound examination, if Doppler testing is abnormal or if the suspicion of pelvic DVT is high, further evaluation is recommended and Magnetic Resonance Imaging MRI may be considered 15, Other examinations that contribute probleme de varicoza deep vein thrombosis or PTE diagnostic great saphenous vein removal are chest X-ray, electrocardiography, ventilation-perfusion lung scanning, computed tomographic CT pulmonary angiography CTPA - the first line test to diagnose pulmonary embolism PE in non-pregnant patients, used with abstention in pregnant patients.

Their contribution is still considerable in ruling out venous thrombembolism in non-pregnant patients Case presentation A year-old primipara presented to the hospital with a history of tobacco use, superficial thrombophlebitis and family thrombotic events mother and sister with DVTreporting burning pain in the right calf accompanied by palpable thrombosed, visibly distended vein of the right lateral calf, local erythema and edema at 13 weeks of gestation.

Physical examination revealed erythema and swelling, consistent with DVT. Therefore, Duplex ultrasonographic US evaluation of the right lower limb was recommended. The test revealed no lack of compressibility of the deep venous system of the lower right limb, but a thrombus was found more than 5 cm below the safenopopliteal junction, affecting 2 cm of the small saphenous vein.

The patient was encouraged to continue her usual daily activities and a treatment with topical heparin and elastic support was recommended. Clinical and US follow-up after 7 days revealed satisfactory progress, relief of pain and swelling with fading erythema.

The patient presented again to our departement, at 22 weeks of gestation, claiming similar symptoms to the previously described episode, this time the pain and distended veins being located in the right internal thigh. The evaluation and management were the same as for the previous episode. Recurrent ST was diagnosed, this time at the level of great saphenous vein, more than 5 cm below the saphenofemoral junction, affecting 3 cm of the vein. Follow-up revealed favorable evolution and remission of symptoms.

The aforementioned testing revealed a negative result.

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At 34 weeks of gestation, the patient presented once again to our department with acute increasing pain and swelling of her right thigh. Duplex ultrasonographic imaging of the right great saphenous vein removal extremity and pelvic veins revealed evidence of intraluminal echogenic material at the level of saphenous arch with 3.

The diagnosis of DVT of the right lower extremity was made, and the patient was admitted to the hospital for further monitoring and treatment. The main objectives for the treatment great saphenous vein removal DVT are to prevent PE, reduce morbidity and prevent or minimize the risk of developing the post-thrombotic syndrome PTS. Laboratory tests were performed to assess hepatic, pancreatic considering recurrent episodes of superficial migratory thrombophlebitis and renal function.

The results came back within normal limits, with a great saphenous vein removal level of 0. Anticoagulation with LWMH enoxaparin, 1 mg per kilogram twice daily, intramuscular was initiated.

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The patient was advised to keep an elevated position of the leg during bedrest in order to reduce swelling and to use compression stockings. The signs and symptoms great saphenous vein removal DVT progressively remitted during hospital stay, and in the absence of new symptoms the patient was disharged one week later after having another Doppler examination performed.

The test showed stable thrombus great saphenous vein removal the aforementioned site. Discharge treatment indication from the hospital included continuation of anticoagulation throughout the pregnancy with tinzaparin units per kilogram once daily, intramuscular. The rest of the pregnancy went uneventful regarding thrombosis-related conditions.

Throughout the pregnancy, the fetus has reached all developemental milestones and no abnormalities were noted. Caesarean section was elected as route of delivery, as the fetus was in breech presentation and the prognoza cu vene varicoase dandelion i vene varicoase scheduled at 39 weeks of gestation.

Anticoagulation was withold 36 hours before surgery, and the procedure went well, with no bleeding complications. To minimize postpartum bleeding complications, thromboprophilactic doses enoxaparin units every 12 hours, intramuscular were resumed 6 hours after caesarean section and therapeutic doses of heparin enoxaparin, 1 mg per kilogram twice daily, intramuscular were delayed until 48 hours after delivery.

The lactation started on second day after delivery and no postpartum complications appeared. Because of neonatal jaundice, the hospital stay of the mother and baby was longer than expected 6 days. Discharge indications for the mother included continuation of anticoagulation for at least 3 months postpartum with tinzaparin units per kilogram once a day, intramuscularclinical and US follow-up 6 weeks postpartum.

The six-week postpartum follow-up revealed favorable outcome. The patient requested ablactation and based on contradictory evidence on the use of warfarin during breastfeeding, the patient was only then switched on oral warfarin 4 mg once a daycoadministered with heparin, with closely monitoring INR level every 48 hours after administration of the dose. Dose adjustments were made in order to reach target INR level of An INR of 2.

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Three months later, the patient underwent compression Doppler ultrasound which exhibited a smaller, stable clot in the same area as the last examination. Warfarin anticoagulation has been further recommended for at least 3 more months in the absence of new symptoms. Currently, the patient is under gynecological routine surveilance in our service and under vascular surveillance in an internal medicine service, and is still under oral anticoagulant therapy.

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Discussions A systematic review recently published suggests that the anatomic distribution of deep vein thrombosis in pregnant women differs from that for non-pregnant patients One may speculate that a May-Thurner-like syndrome caused by compression of the left iliac vein by the gravid uterus, at the point where it crosses the right iliac artery, plays an important role in the increased incidence of left iliofemoral deep vein thrombosis in the third trimester of pregnancy.

This strong evidence makes the anatomical distribution of DVT in the lower right extremity of our patient atypical. Optimal prophylaxys and treatment of thrombotic events are required in order to obtain a good outcome and includes both non-pharmacologic and pharmacologic measures.

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Non-pharmacologic treatment with elastic compression great saphenous vein removal have been shown to lower the pain and swelling associated with deep-vein thrombosis, but their use did not prevent PTS The prophilaxys of thromboembolic events in pregnancy tipically involves unfractionated heparin UFH or low molecular weight heparin LMWHwhich do not cross the placenta or enter breast milk. The subcutaneous route of administration is preferred. UFH was replaced by LMWH use for the treatment of venous thrombembolism in pregnancy, mainly bandaj pentru picioare cu varicoza on extrapolation of data obtained from trials involving non-pregnant patients and observational studies that emphasized the safety of LMWH in prgnancy Moreover, LMWH have been shown not to be associated with an increased risk of severe postpartum hemorrhage Specific agents include dalteparin international units [IU] per kilogram of body weight daily or IU per kilogram twice dailyenoxaparin 1.

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Another therapeutic great saphenous vein removal, warfarin, crosses the placenta and teratogenic effects as chondromalacia, mid-face hypoplasia, scoliosis, short proximal limbs, short fingers and CNS abnormalities have been described when warfarin is administered during the first trimester There is insufficient great saphenous vein removal to evaluate the risks and benefits of direct thrombin inhibitors as dabigatran and anti-factor Xa inhibitors such as rivaroxaban in pregnancy Thrombolysis in pregnancy is exclusively reserved for massive life-threatening PE with altered hemodynamic balance or for proximal deep-vein thrombosis that is compromising leg viability As a limitation of this case report we mention the fact that the novelty of the report does not come from the therapeutic point of view, as the management and treatment do not differ depending on the side of DVT, but from the fact that even if most of the cases of DVT during pregnancy involve the left lower extremity, our patient meets the statistics validated for the general popula­tion and not for pregnant patients, which emphasize the greater frequency of DVT in the right lower extremity.

Moreover, the originality of the reported case stems from the fact that few specific cases on uncomplicated ST and DVT during pregnancy, which describe the complete management of patients, are found in literature, most of the data coming from trials on DVT complications, such as PTE. The screening for inherited thrombophilia was negative, so only when DVT was certified, LMWH therapy was started based on current guidelines.

The treatment options can influence the timing of delivery. Also, the route of delivery should be carefully selected while anticoagulation management should be optimized depending on this aspect. If opting in favour of induced vaginal delivery, temporarily discontinuing the use of LMWH would be prudent to minimize the risk of bleeding and permit epidural anesthesia if required. Women should be counseled to discontinue injections of heparin if labor starts or is suspected.

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Epidural anesthesia is usually delayed until at least 24 hours after the last dose, given a small risk of epidural hematoma associated with administration of epidural anesthesia before that time.

Postpartum, LMWH should only be administered 4 hours after spinal anesthesia or the removal of an epidural catheter. The management of anticoagulation therapy if caesarean section is elected as route of delivery was thoroughly discussed in the above case report.

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In case of early recognition of signd and symptoms of DVT during pregnancy, proper management may be initiated in time and beneficial outcome might be reached. Conclusion Although the anatomical distribution of DVT during pregnancy might be atypical, the awareness of thrombotic events may prevent potentialy life-threatening complications for both the mother and the fetus, and optimal management most probably leads to a favorable outcome.

The autors declare that they have no competing interests. Bibliografie 1.

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Prevalence and predictors for post-thrombotic syndrome 3 to 16 years after pregnancy-related venous thrombosis: a population-based, cross-sectional, case-control study. J Thromb Haemost ; Greer IA. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a year population-based study. Ann Intern Med ; Incidence, clinical characteristics, and timing of objectively diagnosed venous thromboembolism during pregnancy.

Obstet Gynecol ; Thrombosis during pregnancy and the postpartum period. Am J Obstet Gynecol ; Ian A Greer. Pregnancy Complicated by Venous Thrombosis. N Engl J Med ; Risk of a thrombotic event after the 6-week postpartum period. Thrombophilia in pregnancy: a systematic review. Br J Haematol ; Venous thromboembolism during pregnancy and the postpartum period: incidence, risk factors, and mortality.

Ante- and postnatal risk factors of venous thrombosis: a hospital-based case-control study.

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J Thromb Haemost ; Validation of the LEFt score, a newly proposed diagnostic tool for deep vein thrombosis in pregnant women. Thromb Res. Chest ; Suppl: Diagnostic value of single complete compression ultrasonography in pregnant and postpartum women with suspected deep vein thrombosis: prospective study.

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BMJ ; Safety of withholding anticoagulation in pregnant women with suspected deep vein thrombosis following negative serial compression ultrasound and iliac vein imaging. CMAJ ; Diagnosis of deep vein thrombosis and pulmonary embolism in pregnancy: a systematic review. J Thromb Haemost.

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Detection of deep venous thrombosis by magnetic resonance imaging. D-Dimer levels at different stages of pregnancy in Australian women: a single centre study using two different immunoturbidimetric assays.

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Thromb Res ; Anatomic distribution of deep vein thrombosis in pregnancy. Compression stockings to prevent post-thrombotic syndrome: a randomised placebo-controlled trial.