Keywords : acute iliofemoral thrombosis, broad ligament myoma
Deep vein thrombosis is one of the serious complications rarely
seen in myoma of the uterus. The clinical methods used to
diagnose venous thrombosis are of limited value. So, more
objective methods of diagnosis like duplex doppler imaging
are required. In this method, real time ultrasound and doppler
examination are combined to visualize the thrombus and
measure blood flow through the vessels.
A 38 year old unmarried lady was referred for pain and swelling of the left lower limb since 3 days. One year back she was diagnosed to have fibroid uterus. Her menstrual cycles were regular. On abdominal examination, a firm fixed mass of 20 x 15 cm was occupying the lower abdomen. Left lower limb was swollen and tender. Homan’s sign was positive. Sonography of the abdomen showed a large uterine fibroid measuring 23 x17x12 cm. Bilateral mild hydronephrosis was noted. Duplex doppler imaging of left lower limb showed deep vein thrombosis involving left external iliac vein, common femoral vein and popliteal vein. In view of complete iliofemoral block, the patient was given 5000 IU of heparin intravenously as a bolus dose. This was followed by infusion of 25000 IU of heparin in 500 mL of normal saline at 30 mL/ hour. This was continued for 7 days and monitored with clotting time and activated partial thromboplastin time. Later, anticoagulation was continued with injection heparin 5000 IU subcutaneously 6 hourly for 2 weeks. She was also advised complete bed rest with foot end elevation. The objective of prolonged anticoagulation was to organize the clot and prevent pulmonary embolism. Intravenous pylography was done as the iliofemoral thrombosis resolved. It revealed lateral displacement of both the ureters. Heparin was stopped 24 hours prior to surgery. At laparotomy, a large myoma 24 x 20 cm arising from the cervix and body of the uterus, and extending into left broad ligament was noted. Myoma had to be removed piecemeal as there was no plane of cleavage. The remaining part of the uterus was distorted to an extent beyond reconstruction. Hence total abdominal hysterectomy was done. Cut section of the myoma did not reveal a whorl pattern. There was no evidence of hemorrhage or necrosis. Twenty-four hours after surgery, 8 hourly subcutaneous injection of 5000 IU heparin was restarted. On the sixth postoperative day, oral warfarin was started. When prothrombin time was double the control, heparin was discontinued. Sutures were removed and the wound healed well. She was discharged with an advice to take tablet warfarin 7.5 mg daily for 4 weeks. She was also advised to monitor prothombin time once every 3 days.
Acute iliofemoral thrombosis probably occurred due to venous
stasis by the broad ligament myoma. This complication should
be treated initially with intravenous unfractionated heparin as
a bolus. This should be followed by continuous intravenous
infusion at a rate of 1000 IU per hour. Activated partial
thromboplastin time of 1.5-2 times the control level indicates
adequate anticoagulation. Surgery should be undertaken after
the thrombus has become firmly organized and attached to
the vessel wall 1
. When oral anticoagulant therapy is initiated,
it should be overlapped with heparin therapy for 4-5 days
until the international normalized ratio (INR) is greater than
two on two consecutive days. Warfarin therapy is usually
continued for 4-6 weeks 2
. Myomectomy was probably not
possible due to the histological variation noted. In
neurilemmoma like myoma, there is palisading of tumor nuclei
causing a resemblance to nerve sheath tumors 3
. It is important
not to overlook deep vein thrombosis of the pelvic veins on
preoperative evaluation of large uterine myomas. Careful
perioperative management may reduce lethal pulmonary
embolism and may positively affect the prognosis.
