Recurrent miscarriages and chronic iliac vein occlusion secondary to connective tissue disorder
Dr Rabia Mushtaq MBBS, FCPS, MRCOG. Dr Hareem MBBS,
Omar hospital and Cardiac center Lahore , Pakistan
• A 29 years old doctor, married for 3 years, P⁰A⁴. Her first pregnancy was age of 26 in October 2020 with missed miscarriage at 19 weeks gestational age
(according to LMP) fetal growth arrested at 14 weeks. This was managed medically. 3 days after expulsion, she developed right lower limb swelling
resolved spontaneously after 3 weeks of bed rest and painkillers.
• Two months after A¹, she conceived naturally in April 2021 and developed right sided pedal odema at 8th weeks of gestation, pregnancy ended again with
missed miscarriage at 13 weeks gestational age ( according to LMP) with fetal demise at 11 weeks. This was managed medically. Investigations done, her
Anti-phospholipid antibodies IgG was moderately raised and IgM was negative, ANA positive & Anti-SSA positive.
• In August 2021, 3 days after 1st dose of COVID vaccine CANSINO, she again developed right lower limb swelling with severe pain on brisk walk. Doppler
USG of right lower limb done twice at the interval of one month which was normal despite the right lower limb swelling and pedal odema.
• In December 2021 she conceived spontaneously and injection Clexane 80mg S/C OD and Tablet Loprin 75mg OD started at the 4th week of gestation, but
again missed miscarriage occurred at 10th week with fetal demise at 7 weeks. Doppler USG of uterine artery shown strained indices and high resistance
blood flow with fetal demise.
• Diagnosis:
• In view of her right lower limb swelling and opinion was sought from us and in February 2022, CT abdomen pelvis with IV contrast done, showing chronic
occlusion of right common iliac vein with fresh clots formed 3cm below IVC bifurcation. She was given injection Clexane 60mg S/C BD for 3 days then
tablet riveroxaban 15mg BD for 4 days followed by tablet riveroxaban 15mg OD for 6 months . Clots and chronic occlusion resolved completely by March
2021, which was confirmed on Doppler USG of abdomen. Complete recanalization of common iliac and external iliac vein by May 2021 and APLS
antibodies repeated showing Anti-cardiolipin antibodies weakly positive. Pateint was advised against further conception.
• In July 2022 she conceived spontaneously and loprin, prednisolone , Folic Acid and injection Clexane 60mg BD S/C started at 28th day of LMP as soon as
pregnancy test was positive. Doppler USG at 13 weeks shows normal uterine artery and umbilical artery blood flow. Hydroxychloroquin 200mg BD started
as well. Doppler USG at 18 weeks (anomaly scan by dates) shown 17 weeks fetal growth with borderline resistance in uterine and umbilical artery. Thus
dose of injection Clexane is increased from 60mg BD to 80mg BD for 1 week. Doppler USG repeated after 1 week, there was fetal demise with growth at
17 weeks. Maximum blood pressure was 140/90 . Fetal expulsion occurred at 22 weeks by LMP following conservative management.
• Patient is currently taking tab Aspirin 75 mg OD and riveroxaban 15 mg OD and is generally well. The advice to use cintraception has be re-iterated to her