Paper

1. PELVIC VEIN THROMBOSISAND PULMONARY
THROMBOEMBOLISM – A FORGOTTEN
COMPLICATION OF HYSTERECTOMY AND NEED FOR
PROPHYLACTIC HEPARIN

2. INTRODUCTION:
Venous thromboembolism is a potentially catastrophic event and
one of the most dreaded postoperative complications. Despite
increased monitoring of these adverse events and the increased
use of thromboprophylaxis, the incidence of venous
thromboembolism has changed little over the last 25 years. The
reported prevalence of venous thromboembolism after
hysterectomy, the most common major gynecologic surgery
varies from 1 to 12%. Most PE-associated fatalities occur within
30 minutes of onset, leaving a very narrow window for medical
intervention, clinicians must identify those at high risk for VTE
and administer effective thromboprophylaxis to minimize the
occurrence of this potentially preventable cause of death.

3. CASE REPORT:
A 63 year old female ,a homemaker admitted with complaints of
Sudden onset cough and breathing difficulty following food intake ,
with increasing severity for past 24 hrs. She is a known case of Morbid
obesity, Type 2 DM, Systemic hypertension , S/P LAVH+ BSO
(18.10.2022 , outside ) ( POD 2) .
Physical examination afebrile. patient is agitated and tachypneic.She is
morbidly obese class 3 ( BMI > 40 ) and the pulse rate was 110/min and
BP 140/90 mmHg. Her respiratory rate was 40/min ,oxygen
saturation was 68% with room air and 98% in 6lit /min. No cyanosis .
Pain score 2/10-chest. B/L pupil 3mm equal and reactive to light.
Systemic examination showed bilateral wheeze, and crepitus ( R>L ).
Per Abdomen was soft , Bowel sounds heard , evidence of 3
laparoscopic ports .

4. No history of diarrhoea, melena, pain abdomen
No history of burning micturation
No history of Rashes , bleeding manifestations.
No history of headache, seizure, syncope, unilateral limb weakness, slurring of
speech , blurring of vision
FIGURE1 - Electrocardiogram

5. FIGURE 2 : CHEST XRAY AP VIEW

6. FIGURE3 : ECHOCARDIOGRAPHY :
•Mildly dilated Right atrium and Right
ventricle
•Mild TR / PAH +
•Good LV function
•EF 57 %
FIGURE4 : CT CHEST

7. LAB INVESTIGATIONS
PARAMETERS RESULTS
PT-INR 17.4 seconds / 1.36
PLATELET COUNT 1.97 lakhs /cu mm
D-DIMER 962 ng/ml
CRP 35.6 mg/L
TC TOTAL WBC COUNT 11080 cells/cu mm
NEUTROPHILS 82.7 %
Provisional diagnosis of PULMONARY
THROMBOEMBOLISM and ASPIRATION PNEUMONIA /
LRTI in a Known case of
OBESITY( class 3 ) /DM/HTN/endometriosis
Status post LAVH + B/L salphingo-ophorectomy
was made

8. FURTHER
WORKUP-
FIGURE5: CT
PULMONARY
ANGIOGRAM
(21/10/22)

9. FIGURE6 : COLOUR DOPPLER ( Both lower limbs)
STILL, PULMONARY THROMBOEMBOLISM CANNOT BE RULED OUT FOR
THIS CASE , WHY BECAUSE…OF THE RISK FACTORS FOR PELVIC VEIN
THROMBOSIS IN THIS CASE
Morbid obesity
Recent Hysterectomy + BSO
Immobility
Diabetes
Advanced age
Women

10. LIMITATIONS FOR CTPA:
CTPA has high sensitivity and specificity, with PIOPED II trial
demonstrating sensitivity of 83% and specificity of 96%.
The PIOPED study proposed combining
ventilation‐perfusion scanning with clinical probability for
the safe exclusion and diagnosis in a subset of patients. This
strategy does not exclude or diagnose pulmonary embolism
in all suspected cases. The gold standard investigation—
pulmonary angiography—is invasive and carries a
recognised morbidity and mortality. Furthermore, a normal
angiogram is associated with a 1.6% incidence of venous
thromboembolism in the following year.
PULMONOLOGY , CARDIOLOGY , GYNECOLOGY ,
ANAESTHESIA opinion obtained .
Antibiotics and LMWH 0.6ml ( BD ) , along with other
supportive drugs , NIV continued .

11. Patients general condition improved gradually with
reduction in D-DIMER.
On due course of IMCU stay , D-DIMER value starts to fall
and Patients respiration improved eventually.
Patient has been shifted to spl ward and eventually
discharged with maintenance dose of Rivaroxaban 15mg OD
for 3 months

12. CONCLUSION
In our case report, the patient presented with
classical yet vague symptoms of pulmonary
thromboembolism and had multiple risk factors,
however angiogram was negative for
thromboembolic event. Hence , even without the
radiological evidence of thromboembolism, the final
diagnosis was put forward as Pulmonary
thromboembolism.

13. Thank you