Clinical Practice and Cases in Emergency Medicine

Introduction: Diagnosing deep venous thromboses and venous thromboemboli (DVT/VTE) in pregnant patients presents a unique challenge for emergency physicians. The risk of DVT/VTE increases during pregnancy, and the potential consequences of misdiagnoses are severe. Point-of-care ultrasonography (POCUS) is frequently a first-line diagnostic imaging modality. However, recent studies have shown a high incidence of thromboses proximal to the common femoral vein during pregnancy, and these would not be visualized using compressive ultrasonography, which traditionally can only visualize thromboses distal to the femoral vein.

Case Report: A 38-year-old female, 25-weeks primiparous, presented to the emergency department with a three-day history of left lower extremity swelling. Point-of-care three-point compression testing was used to evaluate for a DVT; however, no thrombus was visualized. Given high clinical suspicion, color and spectral Doppler testing were performed and demonstrated turbulent flow and reduced respiratory variation in the common femoral vein. This prompted further additional testing for a proximal DVT using magnetic resonance venography, which revealed an occlusive left external iliac thrombus. The patient was subsequently started on daily subcutaneous enoxaparin and discharged home with close follow-up.

Conclusion: Emergency physicians play a critical role in evaluations for the presence of DVT/VTE, particularly in pregnant patients. We endorse the use of POCUS with three-point compression testing, as well as color and spectral Doppler imaging, to help identify proximal DVTs in this patient population. This case report can aid physicians in the diagnosis of this pathological condition that if left untreated can have severe consequences.