May Turner Syndrome Vascular Condition of Postpartum

Jaya Menon1*, Umarani2, Jane Abishak3, Suriya4

1Nursing Superintendent, Kauvery Heartcity, Trichy, India

2Asst., Nursing Superintendent, Kauvery Heartcity, Trichy, India

3Nursing Supervisor, Kauvery Heartcity, Trichy, India

4Nursing Critical Staff, Kauvery Heartcity, Trichy, India

Definition:

Deep vein thrombosis (DVT) is a condition where a blood clot forms in a deep vein usually in the leg but can also occur in the arm or pelvis.  These clots can form when blood flow is slow or when there’s damage to the vein wall.  If a DVT is not treated the clot can break loose and travel through the blood stream causing a potentially life threatening condition like pulmonary embolism.

Deep vein thrombosis during pregnancy and after delivery:

A deep vein thrombosis is when a blood clot forms in vein deep in your body.  These often occur in a leg vein, but it can also occur in an arm or the pelvic DVT can be dangerous because the blood clot can break off and travel to the lungs.  The clot can stay in a blood vessel of the lungs and block blood flow.

Risk Factor:

Obesity: A BMI of 30 or higher significantly increases the risk to DVT during pregnancy.  Weight management before and during pregnancy can help mitigate this risk.

Smoking: Smoking, especially when combined with other risk factor is a known contributor to DVT.  Quitting smoking before and during pregnancy is crucial for reducing the risk.

Prolonged Co-mobility: Staying sedentary for extended periods such as during long flights or bed rest can lead to blood pooling in the legs and increase the risk of clot formation staying active even with simple leg exercise during prolonged sitting.

Oral contraceptive / Hormone replacement therapy: This medication can increase the risk of blood clots so they should be discussed with a doctor and potentially avoided or managed carefully during pregnancy.

Other Modifiable factors: Condition like hypertension and certain infection can also increase the risk of DVT during pregnancy.

Non-Modifiable Risk Factor:

Inherited Thrombophlebitis: These are genetic conditions that affect the blood’s clotting ability.

Factor Vs Leiden Mutation: A common inherited thrombophlebitis that makes the blood more likely to clot.

Prothrombin 20210A Mutation: Another inherited condition that increases clotting risk.

Other inherited thrombophlebitis: Deficiencies in protein or antithrombin can also predispose individuals to DVT.

Family history of blood clots: Having a close family member with a history of DVT or PE increases risk.

Advanced Maternal Age: Being 35 years or old during pregnancy is associated with a higher risk of DVT.

Multiple Pregnancies: Carrying twins or multiples increases the risk of DVT due to increased pressure on the vein and other physiological changes.

Blood types: Some study suggests that blood type may be a risk factor with some blood types having a higher risk of DVT.

May Turner Syndrome:

Definition:

May turner syndrome is a condition where the right iliac artery compresses the left iliac vein disrupting blood flow and potentially causing DVT.

Modifiable risk factor:

Promoting mobility

Managing thrombophlebitis

Anticoagulation duration

Endovascular intervention

Non – Modifiable risk factor:

Female Sex

Multiparty

Anatomical variations

Pregnancy and post partum

Age

Family history of DVT

Thrombophlebitis

Scoliosis

Anatomy:

Ilio femoral Vein:

The ilio femoral vein is a major vein in the lower limb formed by the union of the external iliac vein and the deep femoral vein and it continues as the femoral vein.  It plays a crucial draining blood from the lower limb back to the heart.

Formation:

The ilio femoral vein is formed by the confluence of the external iliac vein and the deep femoral vein.

Location:

The ilio femoral vein begins in the pelvis and continues into the through where it becomes the femoral vein.

Function:

It primarily serves as a conduct for deoxygenated blood from the lower limb returning it towards to the heart.

Relationship with other vessels:

The ilio femoral vein runs along the corresponding iliac artery and femoral artery.

Tributaries:

The ilio femoral veins receive tributaries from various parts of the lower limb including the deep femoral vein and other smaller veins.

Parts of Vein:

Tunica intima

Tunica media

Tunica Externa

Other important futures:

Valves: Many vein especially in the limbs have valves that prevent back flow of blood and ensure it moves towards the heart.

Vasa vasorum: These tiny blood vessels supply the way of the veins with nutrients and oxygen.

Nervi Vasorum: These nerves help regulate the constriction and dilation of the veins.

Symptoms:

Common Symptoms of DVT in Postpartum mother

Leg pain or tenderness: Pain, cramping soreness that may worsen with walking or standing.

Swelling: Swelling in one leg which may be localized to the calf or thigh involves the entire leg.

Warmer: The affected area of the leg may feel warmer than the other leg.

Redness or discoloration: The skin on the affected leg may appear red or have a change in coour through this may be harder to notice on darker skin tones.

Symptoms of DVT:

  • Throbbing pain in leg usually in the calf or thigh when walking or standing up.
  • Swelling in leg (rarely both leg).
  • Warm skin around the painful area.
  • Red or darkened skin around the painful area this may be harder to see on brown or black skin.

Common Clinical Signs of DVT:

Leg Swelling: Swelling particularly in one leg is a common sign it may be localized to a specific area of involve the entire leg.

Pain or Tenderness: Pain, cramping or soreness in the calf or thigh is frequently reported often worsening with walking or standing. Heavy or aching feeling: Some women describe a heavy aching sensation in the affected leg.

Pathophysiology:

  • Vessel trauma stimulates the clotting cascade.
  • Platelets aggregate at the site particularly when venous stasis is present.
  • Platelets and fibrin from the initial clot.
  • RBC are trapped in the fibrin meshwork.
  • The thrombus propagates in the direction of the blood flow.
  • Inflammation is triggered causing tenderness swelling and erythematic.
  • Pieces of thrombus may break loose and travel through circulation of emboli.
  • Fibroblasts eventually invade the thrombus, scarring vein wall and destroying valves. Patency may be restored valve damaged is permanent affecting directional flow.

Phlegmasia Alba Dolens:

  • Thrombosis is only major deep venous channels sparing collateral vein.
  • Causing painful congestion and edema of leg with lymphangitis.
  • Which further increases edema.

Phlegmasia Cerulea dolens:

  • Thrombosis extends to collateral vein.
  • Congestions are massive fluid sequestration edema.

Clinical Examination:

  • Palpate distal pulses and evaluate capillary refill to cause limb perfusion.
  • Move and palpate all joints to detect acute arthritis or other joint pathology.
  • Neurologic evaluation may detect nerve root irritation, sensory, motor and reflex deficits should be noted.

CECT Abdomen Report:

ECHO Report:

Trimester Down syndrome Report:

Homan’s Sign: Pain in the posterior calf of knee with forced dorsiflexion of the foot.

Moses Sign: Gentle sequencing of the lower part of the calf from side to side.

Leiton’s Sign: After applying tourniquet at sapheno femoral junction patient made to walk then limb is elevated in supine position prominent superficial veins will be observed.

Diagnostic Studies:

Blood Test: D – Dimer

Imaging Studies:

Invasive: Venography

Radiolabeled fibrinogen

Non-Invasive: Ultrasound

Plethysmoqraphy

MRI techniques

Diagnosis:

Acute iliofemoral DVT, SIPLSCS (24.05.25), Good LV Function may turner syndrome.

Course of Study in Hospital:

A 22 years female she was diagnosed acute left iliofemoral DVT, May Turner Syndrome, good LV function.  His CECT abdomen showed left common iliac vein compressed by the right common iliac artery at its origin causing focal narrowing and history of SIPLSCS (24.05.25) and referred here further management.  His ECHO showed good LV function doctor advised planned for IVF further and CDT procedure done (12.06.25) and Inj.heparin 2ml on flow, Inj.Actilyse 3ml on flow, and (13.06.25) check venogram + suction thrombectomy + Left iliac venoplasty done and continued the same medication. On 14.06.25 checked venogram + Leaf CIV stenting done and continued Inj.Heparin 2ml on flow Inj. Actilyse 3ml on flow and 4th pod removed the catheter and sheath; no complications.  His preoperative workups and fitness procedure were done.  The patient underwent successful procedure; his post operative hospital stay was uneventful.  During postoperative period had no complication, the patient condition improved and discharged in a stable hemodynamic status with the following advice.

Pre Op Nursing Management:

Anticoagulation Therapy:

Initiate and mange anticoagulant medication (e.g: Inj.Heparin , Inj.Warfarin or oral anti coagulan).

Pain Management:

Implement strategies to alleviate pain and discomfort associated with DVT, such as elevation of the affected limb warm compresses and analgesics.

Monitoring for Complication:

Closely monitor the patient for signs of clot progression or complication like PE. Excessive bleeding from anticoagulation or infection.

Promoting Circulation:

Encourage early ambulation leg exercise and the use of graduated compression stockings or intermittent pneumatic compression devices to improve blood flow and prevent further clot formation.

Patient Education:

Provide comprehensive education about DVT, its treatment potential complications and the importance of adhering to the prescribed regimens.

Emotional Support:

Often emotional support and address any concerns or anxieties the patient may have regarding their condition and treatment.

Infection Control:

Implement measure to prevent and manage any potential infection that can exacerbate DVT and complicate recovery.

Bleeding Precautions:

Educate patient about bleeding precautions especially, if on anti coagulants including avoiding certain medication.

  • Patient continuous cardiac monitoring.
  • Nurse maintained every hourly vital sign and I/O monitoring.
  • Blood sampling done for Pre op investigation under aseptic technique to prevent thrombophlebitis CBC, D-dimer, Serology, PT INR, CT scan.
  • Doctor explained about risk and benefits of procedure to the attender and informed consent obtained.
  • Skin preparation was done.
  • NPO instruction was explained to the patient.
  • Nurses provided with psychological support.
  • Patient shifted to Cath lab for IVF filter + CDT procedure.

Post Operative Nursing Management:

  • The patient was transferred from the Cath lab to CCU for continuous cardiac monitoring.
  • Nurses monitored and maintained vital sign every 1Hrs.
  • Nurses train in intravenous infusion and blood sampling techniques.
  • Using sterile technique to prevent thrombophlebitis.
  • The doctor explained the patient condition to attenders.
  • Every 12Hrs check the APTT level and every morning check the HB level.
  • Continues infusion of anticoagulant.
  • Watch the procedure site and DV bleeding and hematuria and head ache.
  • 1st to 3 days continue the infusion after the 4th day remove the sheath and femoral bandage.
  • Patient advised for oral intake.
  • Educate the patient, mobilize the leg and walk the patient.
  • Patient shifted to ward.

After delivery 3rd day fever and left leg swelling.  CECT abdomen done.

ECHO Finding:

Normal LV Function

Drug:

Inj.Clexane 60mg BD

Cath Lab Procedure:

12.06.25 – IVC filter placement + CDT

13.06.25 – Check venogram + Suction

Thromberctomy and left liac veno plasty

14.06.25 – Check Venogram + LCIV Stenting.

After procedure medication:

Inj.Actilyre 3ml Onflow

Inj.Heparin 2ml Onflow

Investigation:

14.06.25 – APTT – 28.8 Control – 26.1

Hb – 9.0

Reference:

  1. Burke RM, Rayan SS, Kasirajan K, et al. Unusual case of right-sided May-Thurner syndrome and review of its management. Vascular 2006;14:47-50. 10.2310/6670.2006.00012 – DOI – PubMed.
  2. Fretz V, Binkert CA. Compression of the inferior vena cava by the right iliac artery: a rare variant of May-Thurner syndrome. Cardiovasc Intervent Radiol 2010;33:1060-3. 10.1007/s00270-009-9671-y – DOI – PubMed.
  3. Virchows Archiv. A, Pathological anatomy and histology. – NLM Catalog – NCBI [Internet]. [cited 2020 Jan 11]. Available online: https://www.ncbi.nlm.nih.gov/nlmcatalog?term=0340-1227%5BISSN%5D.
  4. Mcmurrich JP. The occurrence of congenital adhesions in the common iliac veins, and their relation to thrombosis of the femoral and iliac veins. Am J Med Sci 1908;135:342-5. 10.1097/00000441-190803000-00004 – DOI.
  5. Ehrich WE, Krumbhaar EB. A frequent obstructive anomaly of the mouth of the left common iliac vein. Am Heart J 1943;26:737-50. 10.1016/S0002-8703(43)90285-6 – DOI.

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