May-Thurner Syndrome, left iliac vein compression by the right iliac artery, is a congenital permissive lesion that requires an additional insult prior to the onset of symptoms. We present a case of a 31-year-old gravida 1 para 0 at 28.6 weeks who presented to the emergency room with a 2month history of progressive lower left leg swelling since 21.2 weeks' gestation. The patient endorsed incidence of domestic violence at 17 weeks' gestation. The patient had a twin sister who was also pregnant and had not experienced these symptoms. Physical exam revealed 3+ pitting edema in the left lower extremity from ankle to groin. There was left calf tenderness with negative Homan's sign bilaterally. Overall finding on magnetic resonance angiography revealed severe compression of the upper left common iliac vein and lower inferior vena cava by gravid uterus. Conservative management and anticoagulation is instrumental in preventing veno-thromboembolic events in pregnancies complicated by MTS.
A 31-year-old gravida 1, para 0 at 28.6 weeks of gestation presented to the emergency room with a 2-month history of progressive lower left leg swelling since 21.2 weeks of gestation. The patient denied pain, loss of sensation, shortness of breath, and dyspnea on exertion. She had a history of domestic violence at 17 weeks. A physical exam of her lower extremities revealed 3+ pitting edema in the left lower extremity from ankle to groin. The left thigh measured 26 inches and the left calf measured 19 inches. No edema was noted on the right lower extremity. Venous Doppler ultrasounds of bilateral lower extremities yielded negative results for deep vein thrombosis (DVT) on three occasions. Magnetic resonance angiography of the pelvis without contrast revealed no evidence for DVT of the left pelvic veins and no evidence of pelvic mass compression. The overall finding was severe compression of the upper left common iliac vein and lower inferior vena cava by gravid uterus. Clinical suspicion became high for May-Thurner Syndrome (MTS). Few cases of MTS have been identified in pregnancy, and none of these cases present without DVT as a presenting symptom. MTS is extrinsic venous compression caused by the arterial system against bony structures in the ilio-caval territory, leading to formation of venous spurs. Symptomatic patients typically have left lower extremity swelling that often involves the entire limb. Risk factors associated with MTS include female sex, scoliosis, hypercoagulable disorders, and dehydration. There is more research to be done to elicit causes and improve diagnosis of MTS.
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