A 37-year-old pregnant woman with a short cervix and a gestational age of 14 weeks presented to the Department of Obstetrics and Gynecology with right calf pain that worsened with movement. She had been referred by the Department of Maternal and Fetal Medicine for cerclage placement. Her obstetric history was gravida 15, para 0, and aborta 13. The patient’s miscarriages occurred between 12 and 14 weeks. A cerclage had been placed during her fifth pregnancy, but the patient delivered at 20 weeks. The remaining 9 pregnancies resulted similarly, with nonviable preterm deliveries before 20 weeks and gestational ages ranging between 12 and 16 weeks despite similar interventions. The most recent sonogram demonstrated a cervical length of 9 mm with funneling. Results of a workup for thrombophilic disorders were negative. The patient denied any chest pain, shortness of breath, fever, chills, or any other symptoms.
Venous duplex ultrasonography demonstrated an acute occlusive right ISVT (
Figure 1) with no evidence of acute or chronic thromboses in the common femoral, deep femoral, femoral, popliteal, or posterior tibial veins on either side. An osteopathic structural examination performed on the thoracic and lumbar spines and lower extremities revealed that T1-9 was neutral, rotated right, sidebent left; T10-12, flexed, rotated right, sidebent right; L1-2, flexed, sidebent, rotated right; L3-5, flexed, sidebent right, rotated right; and a posterior right fibular head. The right lower extremity starting just below the popliteal fossa posteriorly was visibly more edematous than the left, and prominent TART (tenderness, asymmetry, restricted motion, tissue texture) changes were identified on the right calf.
The patient’s treatment plan was discussed in an interdisciplinary manner among the departments of internal medicine, hematology, vascular surgery, and obstetrics and gynecology. The decision was made to start therapy with heparin. For the short cervix, a rescue McDonald cerclage of the cervix was favored over 17-α-hydroxy-progesterone therapy because of this patient’s risk of clotting. The procedure was uncomplicated, and her fetus was found to be viable. Anticoagulation therapy with enoxaparin sodium was then initiated, prescribed to be taken throughout the pregnancy and postpartum period. She was instructed to follow up with the Department of Maternal and Fetal Medicine in 1 week and to schedule an appointment with her primary care physician.
A week later, the patient presented to the emergency department with complaints of fatigue, dyspnea on exertion, and shortness of breath. During the history-taking portion of the visit, the patient revealed that she had been unable to fill her enoxaparin sodium prescription because of an error at her local pharmacy.
An osteopathic structural examination was performed on the thoracic and lumbar spines, lower extremities, rib cage, and chest wall, which revealed TART changes at T2-4 and identical right lower extremity findings as before: T1-2, neutral, rotated right, sidebent left; T3-4, flexed, rotated right, sidebent right, T5-9, neutral, rotated right, sidebent; T10-12, flexed, rotated right, sidebent right; L1-2, flexed, sidebent, rotated right; L3-5, flexed, rotated right, sidebent right, rotated right; poor cephalad movement of ribs 3 to 10 on inspiration; and an anterior Chapman reflex point at the sternocostal junction in the intercostal space between the right fourth and fifth ribs.
An electrocardiogram revealed sinus tachycardia with a right bundle branch block, and venous duplex ultrasonogram of the right lower extremity demonstrated an occlusion of the soleal vein. A computed tomographic angiogram of the chest revealed an acute arterial pulmonary embolism (PE) with intraluminal filling defects within the distal right main pulmonary artery as well as segmental and subsegmental branches of the right lower and left lower lobes (
Figure 2). Abdominal ultrasonogram showed a viable fetus with no abnormalities.
Anticoagulation therapy with enoxaparin sodium was started. The patient was discharged from the hospital in stable condition 2 days later with instructions to maintain regular follow-up appointments with the Department of Maternal and Fetal Medicine and to follow up in 1 week in the internal medicine clinic.
Three weeks later (at 18 weeks’ gestatiional age), the patient presented to the emergency department, complaints of feeling something protrude through the vagina along with leakage of fluid and decreased fetal movement. On evaluation, the patient was noted to have a segment of the umbilical cord protruding through a partially open cervix. The cerclage was still in place, and fetal heart tones were not detected. At this time, the decision was made to remove the cerclage and to administer misoprosol to induce labor. The patient delivered a nonviable fetus with spontaneous delivery of the placenta. The patient tolerated the procedure without complication and was discharged 2 days later. She was cardiovascularly stable but was advised to continue the prescribed anticoagulation therapy. At the time of hosptial discharge, the patient’s shortness of breath and calf pain had resolved.