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In a five-year case-control study (1988 to 1993) at Assir Central Hospital (ACH), Abha (8,000 feet above sea level), Saudi Arabia, 92 of 129 patients suspected of deep venous thrombosis (DVT) were studied with ascending contrast venography (CV) (74 patients, 80.4%) or Doppler ultrasonography (DUS) (18 patients, 19.6%). Female-to-male ratio was 2.3 to 1. Age range of patients was twelve to ninety years; mean age was 44.45 yrs ±17.38 years. DVT hospital incidence was 18 per 10,000 admissions
leg is cyanotic from massive ileofemoral venous obstruction.
The leg is usually markedly edematous, painful, and cyanotic. Petechiae are often present .
Phlegmasia alba dolens
Painful white inflammation was originally used to describe massive ileofemoral venous thrombosis and associated arterial spasm. The affected extremity is often pale with poor or even absent distal pulses
Superficial thrombophlebitis is characterized by the finding of a palpable, indurate, cordlike, tender, subcutaneous venous segment.
40% of patients with superficial thrombophlebitis without coexisting varicose veins and with no other obvious etiology (eg, intravenous catheters, intravenous drug abuse, soft tissue injury) have an associated DVT
Homans' test Dorsiflexion of foot elicits pain in posterior calf. Warning : it must be noted that it is of little diagnostic value and is theoretically dangerous because of the possibility of dislodgement of loose clot.
Pratt's sign : Squeezing of posterior calf elicits pain.
Score (wells score) Clinical Parameter Score +1 Active cancer (treatment ongoing, or within 6 mo or palliative) +1 Paralysis or recent plaster immobilization of the lower extremities +1 Recently bedridden for >3 d or major surgery <4 wk +1 Localized tenderness along the distribution of the deep venous system +1 Calf swelling >3 cm compared with the asymptomatic leg +1 Pitting edema (greater in the symptomatic leg) +1 Previous DVT documented +1 Collateral superficial veins (nonvaricose) -2 Alternative diagnosis (as likely or greater than that of DVT)
Wells score Total of Above Score > 3 High probability 1 or 2 Moderate probability < 0 Low probability
The gold standard is intravenous venography , which involves injecting a peripheral vein of the affected limb with a contrast agent and taking CT, to reveal whether the venous supply has been obstructed. Because of its invasiveness, this test is rarely performed
High clinical pretest probability- DVT likely Doppler ultrasound Ultrasound positive for DVT Diagnoses of DVT confirmed Begin treatment Ultrasound negative for DVT D-Dmer test (if available and reliable) Otherwise skip to repeat ultrasound D-Dimer positive Repeat ultrasound in 1 week D-Dimer negative DVT ruled out Repeat ultrasound positive for DVT Diagnoses of DVT confirmed Begin treatment Suspect DVT Low clinical pretest probability- DVT likely Consider starting with D-dimer test first (if available and reliable ) Or skip to ultrasound D-dimer positive D-Dimer negative DVT ruled out Doppler ultrasound Ultrasound positive for DVT Diagnose of DVT confirmed Begin treatment Ultrasound negative for DVT DVT ruled out (consider repeat ultrasound if D-dimer not available)
There are two main complications of deep vein thrombosis (DVT):
occurs in 15% of patients with deep vein thrombosis (DVT). It presents with leg oedema, pain, nocturnal cramping, venous claudication, skin pigmentation, dermatitis and ulceratiaion (usually on the medial aspect of the lower leg).
The treatment of DVT in pregnancy is similar to the treatment of non pregnant.
Heparin SC or small pump infusion
avoid warfarin in pregnancy If warfarin therapy is essential, it should be avoided at least during the first trimester (because of teratogenicity) and from about 2 to 4 weeks before delivery to reduce risk of hemorrhagic complications
Prophylaxis for DVT is required in all patients with risk factors. DVT prophylaxis for patients scheduled to undergo major surgery is well recognized.
Recently, a large multicenter double-blind placebo-controlled trial showed that a single subcutaneous 40-mg daily dose of enoxaparin achieved a 63% reduction in the incidence of DVT/PE in general medical patients admitted to the h ospital.
In the Women's Health Study, supplementation with vitamin E (alpha-tocopherol, 600 IU every other day) reduced the risk of venous thrombo embolism in women, especially those with a prior history or genetic predisposition.
High-risk patients should also be prescribed a single prophylactic subcutaneous 40 mg dose of enoxaparin prior to a long plane trip (>6 h).