Case History: 

Mrs. M .H is a 25 years old banker, mother of two healthy children 5 and 3 years old with history of two miscarriages at 16 and 18 weeks of pregnancy. 

On August 29th2000, She presented to the Accident and Emergency room with acute left sided pleuritic chest pain, and low-grade fever for the last three days. 
Mrs. M.H was feeling unwell and was mostly in bed for the last three days after a long trip back from Jordan in a Bus for 14 hours. 

That day afternoon on trying to get out of bed, she felt dizzy, passed out for few minutes and noticed increasing difficulty in breathing and palpitations. 
Past medical history was negative for diabetes, hypertension, cardiac problems or previous thromboembolism; she is on no medications except for birth control pills for the last 2 years. 

The two miscarriages were spontaneous.

On clinical exam. 

She was found tachypneoic RR 281m, Temp.38.2 DC, BP 110nO mmHg, Pulse rate 120/m regular 

02 Saturation via pulse oximetry, on room air, was 95%
No cyanosis, pallor or Jaundice were found 
Normal heart sounds, No added sounds or murmurs, NP was normal 

Chest examination showed, diminished air entry on both bases with bronchial breathing, pleural rub and, tenderness over the Lt. costo -condral junctions 

Lower limb examination showed pitting edema Lt ankle, with negative Homans sign, mild tenderness was detected over the course of the femoral veins, no varicose veins, and no skin changes. 

The following investigations were ordered 

Chest -X-ray ( shown in figure 1.1)
12 leads ECG (shown in figure2.1)
Blood tests: 
HB 11.2gm, HCT 38%, WBC 10.3, PLT 245
Urea /Creatinin ,LFf within normal limits 
ABG on room air as follows PaO2=85, PCO2 =38,
HCO3=18.5 PH= 7.38 
PTT=50 sec. PT= 15 sec. INR=I.2
D- Dimer test was strongly positive 
Blood was collected for Thrombophilias screening, the results were received two days later. 

Radiological diagnostic tests: 

Venous Doppler ultrasound for the lower limbs showed, poor compressibility of the popliteal vein with a floating thrombus on both femoral veins. The patient was admitted to the female medical Ward with the diagnosis of Deep Venous Thromboses and High likelihood of Pulmonary Embolism.

Course in Hospital 

In the A&E she was started on IV Heparin drip 5000 units bolus and 1000 units IV/hour, and 10 mg of Warfarin was given orally. 

The morning after V /Q scan was performed which showed two triple matched segments on the LT. lung lower lobe, and one mismatched segment on the Rt. Side.

The course of the first 3 days was uneventful and the patient showed significant improvement of her symptoms with INR 4.0 on the third day. 

Thrombophilia screening results showed normal levels of ATlII, protein C, Protein S and High level of Lupus Anticoagulant.

The treating physician decided to continue both IV Heparin and Coumadin for another 48 hours 

Day#4 Haemoglobin dropped to 8.2 gm, PLTS dropped to 50,000, INR = 4.3 (on 2mg of coumadin) 

Day #5 the patient condition deteriorated, complained of abdominial pain and noticed reddish discoloration of her urine. 

Hemoglobin dropped further to 6.3gm and platelets dropped further to 30,000 
The treating physician decided to D/C the IV Heparin and transfuses 2 units of Packed RBCs
 
Abdominal Ultrasound showed a retrperitoneal Haematoma, and possible infarction of the Right Kidney. 

Another V/Q scan showed new bilateral mismatched segmental lung lesions 

At that stage a Hematologist was consulted who recommended to stop Coumadin and transfused 4 units of fresh frozen plasma and 1 mg of Vit K2 to correct The INR to 1.4 before performing Bil. Ascending Venogramm which is shown in Fig 1.2,1.3 

Depending on the result of the Venogram a Mobin Udin IVC fIlter was inserted by the Radiologist, and coumadin was restarted 

The patient condition settled down and was sent home after two weeks on 2 mg of coumadin for life and to be followed up in the hematology outpatient clinic. 

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