ABSTRACT

Venous thromboembolism during pregnancy and puerperal period is a known phenomenon.  We are reporting a case of puerperal renal vein thrombosis in a twenty seven year old female which was treated conservatively.  It is rarely reported in English literature.

KEYWORDS  

Puerperal, thrombosis, renal vein

INTRODUCTION

Risk of venous thrombosis and pulmonary embolism during pregnancy and the puerpereum is five times higher compared to those of similar age who are not ¹. Thromboembolic phenomenon remains the leading cause of maternal death in developed countries.  The incidence of thromboembolism in pregnancy is 1:1000 with equal distribution in antepartum and puerpereum ².

Venous thrombosis commonly involves veins of legs and pelvis.  Renal vein thrombosis (RVT) alone is a rare phenomenon.  We describe a case of RVT in puerpereum.

CASE REPORT 

 A twenty seven year old female was admitted with fever and pain in left flank of four days duration.  She had second normal delivery ten days before the present complaints. The first delivery was uneventful.  On examination, she had temperature of 100⁰F, blood pressure 130/80 mm of Hg, pulse rate 96/min, tenderness in left hypochondrium and renal angle, and nontender palpable uterus.  A clinical diagnosis of acute pyelonephritis was made.  Investigations revealed Hb 4.7 gm%, WBC 15,000/ml, platelets 4,30,000/ml,  serum Creatinine 0.5 mg%, blood sugar 86 mg%, urinalysis protein 2+, RBC >100/HPF.  Urine culture was sterile.  Ultrasound (USG) of abdomen showed bulky echogenic left kidney.  Color Doppler study showed left RVT.  Computer tomography (CT) of abdomen (Fig. 1) revealed left RVT extending into inferior vena cava (IVC).  DTPA 99m Tc scan showed GFR of 73.6 ml/min of right kidney and 13 ml/min of left kidney.

She was treated with six units of packed cells transfusions for severe anaemia, low molecular weight heparin (LMWH) and antibiotics.  She responded well to treatment and discharged home on oral anticoagulant.

She was asymptomatic at the end of 3 months.  DTPA 99m Tc scan did not show recovery of left kidney function.

DISCUSSION

Pregnancy fulfills all three criteria described by Virchow for venous thrombosis namely, stasis, hypercoagulability and damage to vessel wall.  Other risk factors are diabetes mellitus, prior thromboembolism, age of 35 years or more, operative delivery, oral contraceptives, hypertension, cancer, obesity, nephrotic syndrome, SLE, smoking, immobility and genetic risk factors for venous thrombosis also known as thrombophilia. Our patient did not have any of these factors present in her.  Investigations for thrombophilia were not available in our institute.

RVT also occurs in neonates and transplant kidney.

Our clinical diagnosis was acute pyelonephritis. We had ordered USG of abdomen as part of routine work up of the patient. Color Doppler study was done by radiologist on his own initiative. That is how RVT was discovered. Otherwise the diagnosis would have been missed.  CT abdomen was done to confirm the diagnosis.  Similar case has been reported in the literature ^{3, 4, 5}. RVT can also occur following puerperal ovarian vein thrombophlebitis ⁶. RVT is treated by LMWH in the initial phase followed by oral anticoagulant for six months.  Recovery of kidney function may ⁴ or may not ⁵ occur following treatment.  In our case there was no recovery of kidney function.

RVT should be considered in any woman with an unexplained flank pain in puerperal period and color Doppler study should be done along with USG of abdomen as a routine work up of the patient.

REFERENCES

1. National Institutes of Health Consensus Development Conference: Prevention of Venous thrombosis and pulmonary embolism. JAMA 1986;256:744.

2. Thromboembolic disorders. In, Cunningham FG, Leveno KL, Hauth JC, GilstrapIII LC, Wenstrom KD (eds). Williams Obstetrics, 22nd edition. New York, McGraw  Hill, 2005; 1073-1091.

3. Rubens D, Sterns RH, Segal AJ. Postpartum renal vein thrombosis. Urol Radiol 1985; 7: 80-84.

4. Patterson RJ, Chisolm A. Puerperal renal vein thrombosis. Obstet & Gynaecol 1983; 62:51s-54s.
5. Mansi MK. Postpartum renal infarction secondary to renal vein thrombosis.  J Urol 2001; 165:893-894.
6. Bahnson RR, Wendel EF, Vogelzang RL. Renal Vein Thrombosis following puerperal ovarian vein thrombophlebitis. Am J Obstet Gynaecol 1985; 152:290-29.