Abstract
A 43-year-old woman presented with severe anaemia secondary to menorrhagia. Pelvic ultrasound showed a large intramural posterior fundal fibroid. Hysteroscopy showed the fibroid distorting the endometrial cavity, precluding Mirena® device insertion. As she was initially hesitant to have a hysterectomy, medical management with the oral contraceptive pill (OCP) and tranexamic acid was instituted, with good effect. Months later, after a long road trip, she presented with left leg swelling, and a Doppler ultrasound confirmed an extensive deep vein thrombosis (DVT). She was commenced on warfarin for anticoagulation but presented again with menorrhagia precipitated by overanticoagulation. After initial stabilization with multiple blood transfusions and reversal of anticoagulation, the warfarin was ceased in favour of enoxaparin and she underwent inferior vena cava (IVC) filter insertion prior to a total abdominal hysterectomy. Mass effect from large uterine fibroids can cause venous thromboembolism (VTE). A duplex ultrasound of the lower limbs if a woman presents with a large fibroid could identify asymptomatic DVTs in such women. A prehysterectomy IVC filter would then reduce their risk of postoperative pulmonary embolism. Medical management of menorrhagia with procoagulants should be avoided for management of menorrhagia in such women given their higher risk of developing VTE.
Highlights
Virchow’s triad of venous stasis, endothelial damage, and hypercoagulability has been used to describe the pathogenesis of venous thromboembolism for over a century [1].Venous stasis is caused by immobility due to recent surgery or illness or a sedentary lifestyle
A hypercoagulable state is caused by multiple factors, such as malignancy, pregnancy, polycythaemia, thrombocytosis, acquired and inherited thrombophilias, use of exogenous oestrogen [2], and other medications such as tranexamic acid [3]
We report a case of a multiple risk factors leading to a massive deep venous thrombosis in a woman with a large uterine leiomyoma
Summary
Virchow’s triad of venous stasis, endothelial damage, and hypercoagulability has been used to describe the pathogenesis of venous thromboembolism for over a century [1]. Women with leiomyomas are at an increased risk of developing venous thromboembolism due to multiple different mechanisms. Polycythaemia and reactive thrombocytosis have been seen in women with menorrhagia due to fibroids [2], and these are risk factors for venous thromboembolism [7, 8]. Mass effect from benign space occupying lesions, including large uterine fibroids, can result in venous stasis of the lower limbs, leading to venous thromboembolism (VTE) [2, 9,10,11,12]. We report a case of a multiple risk factors leading to a massive deep venous thrombosis in a woman with a large uterine leiomyoma
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