Superior vena cava thrombosis after in-vitro-fertilization

History and clinical findings: A 29-year-old female was admitted with the d iagnosis of multiple deep Vein thrombosis of the upper limbs and neck and p neumonia secondary to pulmonary embolism on the right side. Medical history revealed that in vitro fertilization with hormone stimulation had been car ried out 5 weeks before. For ten days the patient had noticed a growing, pa inful swelling on the right side of her neck accompanied by difficulties in swallowing. Since this time she had experienced episodes of shortness of b reath without chest pain. Clinical findings showed a soft and slightly pain ful swelling of the right side of the neck without dyspnoea or cyanosis at rest. Breath sounds were decreased over the right lower lung on auscultatio n. Investigations: Magnetic resonance imaging (MRI) confirmed complete obstruc tion of the subclavian and brachiocephalic vein on the right side and clots in the superior vena cava, left subclavian vein, bilateral internal jugula r veins and the right axillar vein. Chest x-ray showed pleural effusion on the right side. Treatment and course: As the seven-week pregnancy was found not to be viabl e anymore, fibinolysis with streptokinase was started under protection of a temporary cava filter. During the following hours the patient developed se rious bleeding as a complication of this therapy and fibrinolysis had to be discontinued after 16 hours. In subsequent examinations the obstruction of the left internal jugular vein was unchanged but collate; rats around the obstruction were noticed. The other veins affected were open, some with red uced flow. Several risk factors were found in the history of the patient su ch as smoking, immobilization, a positive familiy history, protein 5 defici ency and APC resistance. After 3 weeks of hospital therapy the patient was discharged under oral anticoagulation with coumarin. Conclusion: In vitro fertilization with hormonal stimulation may cause seri ous complications in patients with unknown coagulation disorders or with an ovarian hyperstimulation syndrome. Risk factors for thromboembolism need t o be ruled out carefully before starting the procedure.