Case Summary: 42-year-old woman with a history of multi-nodular goitre, prolactinoma, endometriosis, and polycystic ovarian disease. Following the initiation of oral contraceptive pills (OCPs), on 19th August noticed left leg swelling, 2 days later travelled to Singapore by taking long flight, there because of severe leg pain presented in emergency department (ED) and was found to have deep venous thrombosis (DVT), OCPS were stopped immediately and she was discharged on Rivaroxaban.After few days she travelled back to to UAE, same day presented in ED with shortness of breath, exertional chest pain. The patient's examination indicated noticeable left leg swelling extending to leg, accompanied by positive pitting edema. Lung auscultation revealed clear breath sounds, excluding respiratory abnormalities.Lab results showed an elevated D-dimer level at 2.52 (normal: 0-0.49), indicating increased fibrinolysis and potential thrombotic activity. A thorough thrombophilia screen yielded unremarkable results, discounting hereditary clotting disorders. This information, along with imaging studies, guided the diagnosis and treatment plan for the patient's complex presentation of deep venous thrombosis and pulmonary embolism (PE). Radiological assessments revealed DVT, in left lower limb, affecting the left external iliac vein, common femoral veins, popliteal vein, and proximal posterior tibial vein.CT Angiography identified a PE in the right basal sub-segmental pulmonary artery. CT Abdomen and Pelvis displayed compression of the left common iliac vein by the right iliac artery, causing acute thrombosis—a manifestation of May-Turner syndrome. These findings guided targeted treatment for the patient's complex condition. Management: Patient was initially started on Enoxaparin, After diagnosis Vascular surgery was taken on board underwent Mechanical thrombolysis and angioplasty (special oblique stent). Due to large amount of contrast used, patient developed acute kidney injury creatinine raised to 1.56 (0.5-1)] which was managed with oral fluid encouragement and IV fluids. Was discharged on Enoxaparin twice a day dose for 3 months. Discussion: MTS is an overlooked cause of Venous Thromboembolism, characterized by left common iliac vein compression from the right common iliac artery against the fifth lumbar vertebra. This anatomical variant increases left-sided DVT incidence, contributing to 2-5% of cases. Risk factors include female sex (postpartum, multiparous, or using OCPs), scoliosis, hypercoagulable disorders, and cumulative radiation exposure. MTS may associate with pelvic congestion syndrome, nutcracker syndrome, ruptured iliac vein, retroperitoneal hematoma, or anatomical variations leading to venous compression. Minimally invasive treatments like angioplasty and stenting offer relief, ensuring immediate and long-term patency. In conclusion, this case underscores the importance of early recognition of MTS, especially in women on OCPs presenting with left-sided iliofemoral DVT. The complexity of managing multiple comorbidities necessitates a multidisciplinary approach, involving emergency department teams, vascular surgeons, and specialists. Timely intervention is crucial for preventing serious complications associated with DVT and PE, emphasizing the significance of awareness and collaboration among healthcare professionals.
Keywords: May-thurner syndrome (MTS) with Pulmonary embolism and Deep venous thrombosis after OCP.