Case report
Massive deep vein thrombosis in pregnant women: The importance of individualizing the action plan
Trombosis venosa profunda masiva en gestante: la importancia de individualizar el plan de acción
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Se observaba también extensión del trombo al cayado de la safena.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "D.R. Delgado García, R. Real Valdés, M.L. Serrano Rodríguez, C.R. Molina Mendoza, E. Quílez Caballero, S. García del Valle Manzano" "autores" => array:6 [ 0 => array:2 [ "nombre" => "D.R." "apellidos" => "Delgado García" ] 1 => array:2 [ "nombre" => "R." "apellidos" => "Real Valdés" ] 2 => array:2 [ "nombre" => "M.L." "apellidos" => "Serrano Rodríguez" ] 3 => array:2 [ "nombre" => "C.R." "apellidos" => "Molina Mendoza" ] 4 => array:2 [ "nombre" => "E." "apellidos" => "Quílez Caballero" ] 5 => array:2 [ "nombre" => "S." 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Delgado García, R. Real Valdés, M.L. Serrano Rodríguez, C.R. Molina Mendoza, E. Quílez Caballero, S. García del Valle Manzano" "autores" => array:6 [ 0 => array:4 [ "nombre" => "D.R." "apellidos" => "Delgado García" "email" => array:1 [ 0 => "dadegar@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "R." "apellidos" => "Real Valdés" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "M.L." "apellidos" => "Serrano Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "C.R." "apellidos" => "Molina Mendoza" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "E." "apellidos" => "Quílez Caballero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "S." "apellidos" => "García del Valle Manzano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Universitario Fundación, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital Universitario Rey Juan Carlos, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Trombosis venosa profunda masiva en gestante: la importancia de individualizar el plan de acción" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1256 "Ancho" => 905 "Tamanyo" => 79576 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0225" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Posterior phlebography (A) showing complete resolution of left external iliac vein thrombosis with slight residual stenosis in the ipsilateral common iliac vein (white circle).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is a life-threatening condition that affects pregnant women nearly 5 times more often than other females patients. In fact, VTE is the leading direct cause of maternal death in high-income countries<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">DVT in pregnant women usually occurs at the ileo-femoral level, while in non-pregnant women it is usually found at the popliteal-femoral level. This location in pregnant women increases the risk of PE<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Other factors, in addition to the physiological changes typical of pregnancy (the Virchow triad: hypercoagulability, venous stasis, and endothelial damage in pelvic vessels) can contribute to an increased risk of thrombosis. These include pre-existing factors (personal or family history of thrombosis, thrombophilia, maternal age over 35 years, obesity, diabetes, multiparity [>2] or smoking), obstetric factors (multiple pregnancy, caesarean section, preeclampsia or prolonged labour) and transient factors (hyperemesis, ovarian hyperstimulation syndrome, immobilization, or surgery during pregnancy or the puerperium)<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 40-year-old woman, primigravida, with a personal history of curettage due to miscarriage of twins, and a maternal family history of superficial thrombophlebitis, presented at the emergency department in her 31st week of pregnancy with swelling in the left lower limb (LLL), redness and pain on exploration, with positive Homans sign, all of which are classic signs of DVT. Given the high clinical suspicion of DVT, an ECHO-doppler was performed in which thrombosis in the external iliac, common femoral, superficial femoral, and left popliteal veins was diagnosed (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>) and therapeutic dose of low molecular weight heparin (LMWH) was started — in this case, enoxaparin at 1<span class="elsevierStyleHsp" style=""></span>mg/kg every 12<span class="elsevierStyleHsp" style=""></span>h. Coagulation parameters in the blood test were in normal ranges, and the antiphospholipid syndrome study was negative, so antiplatelet therapy was not added to the treatment.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Five weeks later, a new ECHO-doppler was performed, which showed radiological improvement in the iliac and superficial femoral veins, with persistent thrombosis in the common femoral, saphenous arch, and left popliteal vein (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Following a meeting between the Anaesthesiology, Haematology and Obstetrics departments, and given the high risk of progression to PE, it was decided to schedule a caesarean section at week 38 of pregnancy. Accordingly, the patient was admitted 48<span class="elsevierStyleHsp" style=""></span>h before the procedure to start anticoagulation therapy with perfusion of unfractionated heparin (UFH) in order to minimise the periprocedural anticoagulation window.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">After admission, the patient was informed of the risk of thrombotic and haemorrhagic events both during caesarean section and in the puerperium, and intravenous perfusion of UFH was started at 1000<span class="elsevierStyleHsp" style=""></span>IU/h, monitored with serial laboratory tests to determine anti-factor-Xa (anti-Xa) activity levels. The patient was also given compression stockings. On the day of surgery, UFH perfusion was suspended 4<span class="elsevierStyleHsp" style=""></span>h before the caesarean section after labs confirmed that blood levels were within the safe range to perform both intradural anaesthesia and the intervention itself (anti-Xa 0.1<span class="elsevierStyleHsp" style=""></span>IU/mL), which are the levels established in our hospital protocol for the suspension and restart of perioperative anticoagulation. This recommendation is based in turn on the periprocedural antithrombotic treatment protocols published by the Spanish Society of Anaesthesiology and Resuscitation (SEDAR)<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>. The patient was monitored with pulse oximetry, electrocardiography (ECG), non-invasive blood pressure. Oxygen was delivered using nasal prongs, and blood oxygen was monitored with capnography. After antibiotic and antiemetic prophylaxis, subarachnoid anaesthesia was performed with 8<span class="elsevierStyleHsp" style=""></span>mg of hyperbaric bupivacaine plus 15<span class="elsevierStyleHsp" style=""></span>mcg of fentanyl. Following this, caesarean section was performed, which was uneventful for both the mother and infant; 100<span class="elsevierStyleHsp" style=""></span>mcg of IV carbetocin was administered to prevent uterine atony, and bleeding was limited to around 600<span class="elsevierStyleHsp" style=""></span>cc. The infant was a baby boy, weighing 3760<span class="elsevierStyleHsp" style=""></span>g, with an Apgar score of 9/10. Four hours after the intervention, with the patient haemodynamically stable, eupnoeic, with normal lower limb strength and sensitivity, contracted uterus, and no signs of active bleeding, UFH perfusion was restarted and increased step-wise to 1400<span class="elsevierStyleHsp" style=""></span>IU/h guided by serial anti-Xa assay to achieve levels of 0.7<span class="elsevierStyleHsp" style=""></span>IU/mL. The mother remained in the post anaesthesia care unit for close monitoring; 24<span class="elsevierStyleHsp" style=""></span>h after the caesarean section, UFH was switched to LMWH (enoxaparin 60<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>h) and the patient was transferred to the hospital ward. She was discharged home 72<span class="elsevierStyleHsp" style=""></span>h after the procedure with the prescribed anticoagulant treatment.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The aetiological study performed <span class="elsevierStyleItalic">a posteriori</span> revealed stenosis of the left common iliac vein and heterozygous mutation of the prothrombin gene 20210A. A phlebography performed 6 months after the caesarean section showed resolution of the thrombus in the left external iliac vein (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>); however, LMWH was continued for a further 6 months, under observation.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">DVT and its dreaded complication PE are the first direct cause of mortality in pregnant women in high-income countries<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4</span></a>. In the case described above, the patient was at high risk of PE due to her massive DVT, and for this reason it was vitally important to minimise the therapeutic window<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a>. The main uncertainty in this patient at high thromboembolic risk was the route of delivery: caesarean section or induced labour. Taking into consideration the risk of PE, the unpredictability of inducing labour in a 40-year-old primigravida, the contraindication for an epidural catheter in a patient receiving active anticoagulant therapy, and in order to avoid the risk of an emergency situation (instrumented delivery, emergent caesarean section, obstetric haemorrhage), our multidisciplinary team agreed that the safest scenario for the patient was to change LMWH to UFH and suspend this treatment a few hours before performing a scheduled caesarean section. UFH was safer than LMWH in this case, because its effect dissipates within 4<span class="elsevierStyleHsp" style=""></span>h of interruption, and it can be reversed using agents such as protamine sulfate<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Caesarean section is certainly a prothrombotic procedure in itself; however, as the thrombus was already established in this case, we focused on avoiding progression to PE as far as possible, and the plan described above allowed us to reduce the therapeutic window to just 9<span class="elsevierStyleHsp" style=""></span>h. With induced labour we would have been unable to calculate the therapeutic window with any degree of certainty, and the possibility of performing epidural analgesia was all but ruled out.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The anti-Xa assay was used to monitor UFH activity because, compared to activated partial thromboplastin time (aPTT), this test shortens the time needed to achieve a therapeutic response, is less variable (resulting in fewer dose changes and fewer tests requested), does not give spurious results in patients with factor deficiencies, lupus anticoagulants or increased acute phase reactants, and results are less affected by biological variables<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>. In the AntiXa assay, therapeutic heparinemia levels with UFH are between 0.3 and 0.7<span class="elsevierStyleHsp" style=""></span>IU/mL, which corresponds to an aPTT of approximately 1.5–2.5 times the baseline value<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>. Therefore, we believe it is reasonable to use the anti-Xa assay to measure heparin (LMWH and UFH) activity, particularly in complicated cases (high or low weight [>90<span class="elsevierStyleHsp" style=""></span>kg or <50<span class="elsevierStyleHsp" style=""></span>kg], kidney failure, or recurrent DVT)<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>.</p><p id="par0055" class="elsevierStylePara elsevierViewall">We also considered performing endovascular placement of a vena cava filter to prevent thrombus migration; however, despite the patient’s high risk profile (extensive ileo-femoral region, third trimester, need for controlled anticoagulation suspension for vaginal delivery or caesarean section), she did not meet the criteria for implantation (anticoagulant therapy contraindicated due to heparin-induced adverse effects, allergy to heparins, or significant bleeding in the context of anticoagulation therapy, high risk of postoperative morbidity and mortality due to bleeding and/or progression of thrombosis despite correct anticoagulant treatment)<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,7,9</span></a>, even though vena cava filter are safe in pregnancy, and complications are similar in pregnant and non-pregnant women<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a>.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Nonpharmacologic thromboprophylaxis includes adequate hydration, early mobilization, and elastic or pneumatic compression stockings. No trials have so far supported the use of compression stockings in pregnancy, and recommendations are derived from evidence in non-pregnant hospitalised patients<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. Despite the controversy surrounding the use of compression stockings for acute management of VTE, one guideline at least recommends applying a graduated elastic compression stocking to reduce oedema in the initial management of DVT<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>, so we chose to use them.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Pregnancy-associated thromboembolisms are relatively frequent and must be studied to determine their origin, since they are frequently associated with haematological diseases or anatomical malformations. In conclusion, it is best to take an individualised approach to the anaesthesia and obstetric management of pregnant women with massive DVT and the type of delivery that is safest for both the mother and infant must be decided by a multidisciplinary team. It is important to ensure good coordination between the services involved and adherence to institutional, national or international protocols.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The patient was fully informed and gave her written consent for the publication of the clinical case.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Funding</span><p id="par0075" class="elsevierStylePara elsevierViewall">This study did not receive any financial support.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interests</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1776682" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1560084" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1776683" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1560085" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Funding" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-02-07" "fechaAceptado" => "2021-07-06" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1560084" "palabras" => array:8 [ 0 => "Deep venous thrombosis" 1 => "Caesarean section" 2 => "Obstetric anesthesia" 3 => "Anesthesia" 4 => "Obstetrics" 5 => "Pulmonary embolism" 6 => "Heparin" 7 => "Anticoagulation" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1560085" "palabras" => array:8 [ 0 => "Trombosis venosa profunda" 1 => "Cesárea" 2 => "Anestesia obstétrica" 3 => "Anestesia" 4 => "Obstetricia" 5 => "Tromboembolismo pulmonar" 6 => "Heparina" 7 => "Anticoagulación" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a potentially lethal condition to be taken into account in pregnant women, where the situation is favored by the characteristic physiological changes of the pregnancy, childbirth and the puerperium. The management of this pathology in this type of patient is based on anticoagulation, with the benefits and drawbacks that this implies. We present the case of a pregnant woman with massive DVT and the issues are discussed, such as the method of delivery (vaginal vs. cesarean section) or the management of treatment (LMWH vs. UFH) in order to obtain the safest situation for the patient.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El tromboembolismo venoso (TEV), incluida la trombosis venosa profunda (TVP) y la embolia pulmonar (TEP) es una afección potencialmente letal y a tener en cuenta en mujeres embarazadas, donde la situación es favorecida por los cambios fisiológicos característicos de la gestación, el parto y el puerperio. El manejo de esta patología en este tipo de pacientes está basado en la anticoagulación, con los beneficios e inconvenientes que ello implica. Presentamos el caso de una mujer embarazada con TVP masiva e intentamos arrojar luz sobre temas como son la vía de parto (vaginal vs. cesárea) o el manejo del tratamiento (heparina de bajo peso molecular [HBPM] vs. heparina no fraccionada [HNF]) de cara a obtener la situación más segura para la paciente.</p></span>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 961 "Ancho" => 2508 "Tamanyo" => 258878 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0210" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Venous Doppler of the left lower limb in B mode (A) and colour Doppler mode (B) showing the common femoral vein (arrowhead) at the level of the arch of the great saphenous vein (arrow), dilated, with heterogeneous, predominantly hyperechoic content and no vascular flow in Doppler mode (B), not compressible with manual compression manoeuvres, consistent with deep vein thrombosis. We also observed the thrombus extending to the saphenous arch.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1227 "Ancho" => 2508 "Tamanyo" => 347445 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0215" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The thrombus extends distally to the superficial femoral veins (arrowhead in A) and the popliteal vein (arrow in B). The infrapopliteal territory is patent.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2531 "Ancho" => 2925 "Tamanyo" => 699714 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0220" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Ultrasound follow up 5 weeks later (A), showing radiological improvement consisting of partial repermeabilization of the veins of the left lower limb with greater manual compressibility of the common femoral veins (arrow) and popliteal vein (arrowhead).</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1256 "Ancho" => 905 "Tamanyo" => 79576 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0225" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Posterior phlebography (A) showing complete resolution of left external iliac vein thrombosis with slight residual stenosis in the ipsilateral common iliac vein (white circle).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "United Kingdom recommendations for obstetric venous thromboembolism prophylaxis: evidence and rationale" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.C. 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Green top guideline" ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Gynaecologists R" "fecha" => "2015" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000006900000008/v1_202209300620/S2341192922001366/v1_202209300620/en/main.assets" "Apartado" => array:4 [ "identificador" => "65601" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Report" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006900000008/v1_202209300620/S2341192922001366/v1_202209300620/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192922001366?idApp=UINPBA00004N" ]
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