Deep vein thrombosis

Diagnosis: The suspected deep vein thrombosis in the pregnancy (the third trimester, the hypercoagulable state, the left-leg predilection from the iliac compression by the gravid uterus).^[1]

The diagnostic approach: The compression ultrasound of the left leg (the proximal or the whole-leg). The D-dimer is less useful in the pregnancy (it is elevated physiologically and by the pregnancy complications), but it may support the exclusion in the low-probability case. The Wells score is applied, with the pregnancy-adjusted consideration. The compression ultrasound is the diagnostic test; if negative and the suspicion persists, the repeat in one week.^[1][4][6]

The management:

• The low-molecular-weight heparin (the enoxaparin, the dalteparin), the weight-adjusted, the first-line in the pregnancy. The direct oral anticoagulants and the warfarin are CONTRAINDICATED (the warfarin is teratogenic; the DOACs in the pregnancy).^[5]
• The continuation for the minimum of the 3 months and at least 6 weeks postpartum, then the reassessment; the switch to the warfarin or the DOAC postpartum (the warfarin is safe in the breastfeeding).^[5]
• The avoidance of the strict bed rest; the early ambulation.^[3]
• The compression stockings for the symptom relief.^[1]
• The obstetric and the haematology involvement.^[5]

The disposition: The outpatient management with the low-molecular-weight heparin and the outpatient follow-up, unless the extensive iliofemoral DVT or the pulmonary-embolism concern warrants the admission.^[1]

The differential: the ruptured Baker cyst (the knee osteoarthritis), the cellulitis, the superficial thrombophlebitis, and the muscle tear — distinguished by the ultrasound.^[1]