Anaesthetic management of emergency caesarean section followed by pulmonary embolectomy

Treatment options for severe pulmonary embolism during pregnancy and the postpartum period: a systematic review

Essentials The evidence on how to manage life-threatening pregnancy-related pulmonary embolism (PE) is scarce. We systematically reviewed all available cases of (sub)massive PE until December 2016. Thrombolysis in such severe PE was associated with a high maternal survival (94%). The major bleeding risk was much greater in the postpartum (58%) than antepartum period (18%).

SUMMARY

Background Massive pulmonary embolism (PE) during pregnancy or the postpartum period is a rare but dramatic event. Our aim was to systematically review the evidence to guide its management. Methods We searched Pubmed, Embase, conference proceedings and the RIETE registry for published cases of severe (submassive/massive) PE treated with thrombolysis, percutaneous or surgical thrombectomy and/or extracorporeal membrane oxygenation (ECMO), occurring during pregnancy or within 6 weeks of delivery. Main outcomes were maternal survival and major bleeding, premature delivery, and fetal survival and bleeding. Results We found 127 cases of severe PE (at least 83% massive; 23% with cardiac arrest) treated with at least one modality. Among 83 women with thrombolysis, survival was 94% (95% CI, 86-98). The risk of major bleeding was 17.5% during pregnancy and 58.3% in the postpartum period, mainly because of severe postpartum hemorrhages. Fetal deaths possibly related to PE or its treatment occurred in 12.0% of cases treated during pregnancy. Among 36 women with surgical thrombectomy, maternal survival and risk of major bleeding were 86.1% (95% CI, 71-95) and 20.0%, with fetal deaths possibly related to surgery in 20.0%. About half of severe postpartum PEs occurred within 24 h of delivery. Conclusions Published cases of thrombolysis for massive PE during pregnancy and the postpartum period suggest a high maternal and fetal survival (94% and 88%). In the postpartum period, given the high risk of major bleeding with thrombolysis, other therapeutic options (catheter [or surgical] thrombectomy, ECMO) may be considered if available.

Emergent surgical pulmonary embolectomy in a pregnant woman: case report and literature review

Acute pulmonary embolism is a leading cause of death during pregnancy and delivery in the United States. We describe the case of a 25-year-old woman who presented in cardiogenic shock in week 38 of her first pregnancy. After the emergent cesarean delivery of a healthy male neonate, the mother underwent immediate surgical pulmonary embolectomy. We confirmed the diagnosis of pulmonary embolism intraoperatively by means of transesophageal echocardiography and removed large clots from the patient's pulmonary arteries. Mother and child were doing well, 27 months later. In addition to presenting our patient's case, we discuss the other relevant reports and the options for treating massive pulmonary embolism during pregnancy.

Thrombolysis for the management of massive pulmonary embolism in pregnancy

Massive pulmonary embolism in pregnancy is a major cause of maternal mortality; the management is challenging, and often requires aggressive therapy. Thrombolysis has been used, often with favorable outcome, but has not been previously reported in a patient presenting with an intrauterine death. We present a 29-year-old nulliparous patient who had a massive pulmonary embolus associated with fetal death in the third trimester of pregnancy. Diagnosis of pulmonary embolus was aided by transthoracic echocardiography and the patient was successfully treated with streptokinase.

Venous thromboembolism in pregnancy

In Western nations, venous thromboembolism (VTE) is an important cause of morbidity and the most common cause of maternal death during pregnancy and the puerperium. Pregnancy is a hypercoagulable state in which coagulation is activated and thrombolysis inhibited. This prothrombotic risk is compounded when hereditary and acquired thrombophilias and other prothrombotic risk factors are present. The risk of venous thrombotic events is increased fivefold during pregnancy and 60-fold in the first 3 months after delivery (postpartum period) compared with nonpregnant women. Many of the signs and symptoms of VTE overlap those of a normal pregnancy, which complicates the diagnosis. Patients with history of previous VTE should use graduated compression stockings throughout pregnancy and the puerperium, and should receive postpartum anticoagulant prophylaxis. The indications for antepartum anticoagulant prophylaxis are somewhat controversial. This article reviews the management of VTE during pregnancy and in the postpartum period.

Outcome of cardiovascular surgery and pregnancy: a systematic review of the period 1984-1996

The outcomes of cardiovascular operations during pregnancy, at delivery, and post partum were reviewed from published material in the period 1984-1996. Surgery during pregnancy resulted in fetal-neonatal morbidity and mortality of 9% and 30%, respectively, and in maternal morbidity and mortality of 24% and 6%, respectively. Duration of pregnancy at surgery and duration and temperature of cardiopulmonary bypass did not influence fetal-neonatal outcome. Maternal complications and mortality of surgery immediately after delivery were 29% and 12%, respectively, and for surgery performed with a postpartum interval the respective rates were 38% and 14%. Hospitalization after week 27 of gestation and extreme emergency contributed significantly to poor maternal outcome. Maternal deaths were reported in 9% of valvular procedures and in 22% of aortic or arterial dissection repairs and pulmonary embolectomies. Fetal-neonatal risks of maternal surgery during pregnancy are high and unpredictable. Maternal risks of cardiovascular procedures during pregnancy are moderate, significantly increase if an operation is performed at or after delivery, and, overall, should be considered as higher than those in nonpregnant cardiovascular surgical patients.

Massive pulmonary embolism in late pregnancy

PURPOSE

To describe the management problems presented by a case of acute massive pulmonary embolism in a labouring woman.

CLINICAL FEATURES

A case of massive pulmonary embolism is described in a woman who presented in early labour at thirty-eight weeks gestation. Immediate management involved the administration of oxygen and intravenous heparin, and transfer to the regional cardiothoracic centre. Pulmonary angiography confirmed the diagnosis of massive pulmonary embolism, but attempts at percutaneous catheter disruption of the clot were of only temporary benefit. The patient subsequently underwent Caesarean section under general anaesthesia, followed minutes later (because of an abrupt deterioration in her condition) by surgical pulmonary embolectomy. The outcome was successful for both mother and child.

CONCLUSION

In cases of acute massive pulmonary embolism presenting in late pregnancy and in labour, the risks and benefits of surgical embolectomy, pharmacological thrombolysis, or attempts at mechanical clot disruption have to be weighed on an individual basis. Management at the referral centre was facilitated by having cardiothoracic and obstetric facilities on the same site.

Cardiac arrest due to massive pulmonary embolism following caesarean section. Successful resuscitation and pulmonary embolectomy

A woman developed pulmonary embolism with cardiac arrest after caesarean section. Cardiopulmonary resuscitation was performed for 45 min during which echocardiography showed right ventricular dilatation. After stabilization, but still in a critical condition, the patient was transferred by airambulance to a hospital with facilities for extracorporeal circulation. A massive embolus was removed. Some hours after extubation the patient developed respiratory insufficiency and hypovolaemia. Re-intubation was followed by severe hypotension requiring external cardiac compression for about 15 min. An emergency explorative laparotomy revealed a ruptured liver with a subcapsular haematoma. A critical illness polyneuropathy made prolonged ventilatory support necessary. She recovered without cerebral sequelae.