A 30 year old G2P1001 sub-Saharan African female teacher at 11 weeks amenorrhea, presented to the Nkwen Baptist Health Center (Bamenda, North West Region of Cameroon) on the 15th of May 2016 with bilateral lower limb swelling and pain of 5 days duration. She had no known chronic illness and denied having a family history of VTE.
She reported being well till 2 weeks prior to presentation when she started experiencing abdominal pains; the pain was mainly in her lower abdomen, dull in nature, non-radiating, mild in intensity, was initially intermittent then became constant. It was associated with intermittent low grade fever. This prompted her to consult at a remote health center, where a urinalysis and malaria parasite test was done but their results were inconclusive. She was then cautioned to be having early pregnancy symptoms and placed on acetaminophen 3 g per day in three divided doses which she took for a week with no regression of symptoms. The persistent and progressively worsening pain now localized at the right lower quadrant prompted a second consultation at another health facility. This pain was still associated with low grade fever and now included; loss of appetite and intermittent postprandial vomiting. The attending physician on examination remarked right iliac fossa tenderness and rebound tenderness with a positive Rovsing’s sign. Presumptive diagnosis of acute appendicitis and differential of ovarian cyst in pregnancy were retained. An emergency surgery was booked. However, intra-operative findings revealed a normal appendix and ovaries.
Following surgery, lower abdominal pains persisted and she complained of a sudden onset of crampy constant pains in her right thigh. She was told to be having post surgery pain, for which she was then given analgesics. On day 3 post hospitalization she was discharged on analgesics, antibiotics and progesterone suppository. While at home, the pains persisted and 2 days later involved her left calf area. This was associated with bilateral lower limb swelling that was more on the right lower limb. The pain increased in severity making it difficult for her to walk. This prompted consultation at our health facility.
On arrival she was ill-looking and in painful distress. Her blood pressure was 122/76 mmHg, heart rate 94 beats/min, respiratory rate of 22 breaths/min, temperature 37 °C, O2 saturation at 97% and weight 58 kg. Her conjunctivae were pink and sclera anicteric, heart sounds were normal and lung fields clear. On examining the abdomen, a clean midline incision was seen and there was tenderness on deep palpation of the lower abdominal quadrants marked on the right. There was bilateral lower limb pitting oedema extending to the thighs with right lower limb more swollen than left. The limbs were mildly erythematous but there was no area of cracked skin or wound on both limbs that could have served as portal of entry for skin infection. Both lower limbs were warm tender.
Based on these we made a tentative diagnosis of bilateral lower limb deep venous thrombosis in early pregnancy with a possible pelvic vein thrombosis that was misdiagnosed for acute appendicitis. Our health facility was not equipped with the necessary tools and personnel to confirm our diagnosis and manage the patient. She was therefore referred to a tertiary care center about 40 km from our facility.
At the tertiary center compressive doppler ultrasound of the pelvis and lower limbs revealed pelvic and bilateral lower extremity veins seen with echoes in the right common iliac vein (Fig. 1), right femoral vein, left femoral vein and left popliteal vein. There was decreased colour flow in these veins and decreased compressibility. These suggested DVT of the right common iliac vein, right femoral vein, left femoral vein and left popliteal vein and thus confirmed our diagnosis of bilateral lower limb and pelvic DVT.
Further laboratory testing showed the following: normal white cell count of 8100/µl, mild anaemia with haemoglobin of 9.8 g/dl, thrombocytosis of 532,000/µl, normal kidney function test (serum creatinine of 0.64 mg/dl and urea of 12.7 mg/dl), glycaemia of 85.9 mg/dl and normal serum electrolytes of: (Sodium 134 mmol/l, Potassium of 4.17 mmol/l and Chloride of 103 mmol/l). Cardiac echography and electrocardiogram done were all normal.
The patient was immediately started on low molecular weight heparin (LMWH) 80 mg subcutaneous route daily. After 5 days of treatment the patient’s symptoms had subsided and she was discharge and counter referred for continuation of care. We continued her daily LMWH injections and scheduled her for a repeat of the pelvic and lower limb ultrasound. Six weeks later there were no more echoes in the pelvic and lower limb veins (Fig. 2). She continued daily LMWH till 12 weeks postpartum.