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A pregnant patient with bilateral ischaemic limbs
  1. N B Teo,
  2. N Mamode,
  3. D P Leiberman
  1. Peripheral Vascular Unit, Royal Infirmary Glasgow, Glasgow, UK
  1. Mr N B Teo, Pathology Department, University of Liverpool, Duncan Building, Daulby Street, Liverpool L69 3GA, UK (email:teonb{at}liverpool.ac.uk)

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Answers on p 666.

A 29 year old pregnant woman, at 35 weeks' gestation, was admitted with a three day history of a painful left thigh and calf which was exacerbated by walking. She also complained of paraesthesiae, muscle weakness, and coldness of the left foot which at times became cyanosed. These symptoms were associated with dyspnoea on exertion.

When admitted to the obstetric ward, the left lower limb pulses were impalpable. The left lower leg was mottled and cold but was viable.

The electrocardiogram showed ST changes in the septal leads with R waves in V1 suggestive of right ventricular hypertrophy as well as T wave inversion in the anterolateral leads thought by the cardiologist to be suggestive of pulmonary thromboembolism. Chest radiography showed cardiomegaly. Full blood count, concentrations of urea and electrolytes, and thrombophilia screen were normal.

On review by the vascular team, it was noted that apart from a very weak right femoral pulse, there was absence of pulses in both lower limbs, which were significantly ischaemic.

After cardiological review, a transthoracic echocardiogram showed a large right ventricle with a dilated pulmonary artery. No atrial septal defect was seen and there was no evidence of thrombus.

Doppler ultrasound showed a 10 cm left popliteal venous thrombus as well as occlusion of bilateral common femoral and superficial arteries. This was followed by a transradial arteriogram that showed the thrombus causing a left common iliac occlusion and a right common femoral arterial occlusion (fig1).

Figure 1

Transradial arteriogram: left common iliac and right common femoral arterial occlusions.

Questions

(1)
What is the diagnosis?
(2)
Describe the pathogenesis of this clinical condition?
(3)
How should the diagnosis be made?
(4)
Describe the most recent development in the diagnosis of this condition?
(5)
What is the treatment?

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