Pulmonary embolism and amniotic fluid embolism in pregnancy

Lung iodine mapping images of acute postpartum dyspnea without pulmonary thromboembolism using dual-energy CT

BACKGROUND

Postpartum dyspnea is commonly observed, but its cause is often unknown.

PURPOSE

To investigate postpartum dyspnea, we compared lung iodine mapping (LIM) using dual-energy computed tomography (DECT) between postpartum women and women suspected of having pulmonary thromboembolism (PTE).

MATERIAL AND METHODS

In this retrospective study, 109 women of reproductive age (50 postpartum women, 59 women unrelated to pregnancy) underwent DECT between March 2009 and August 2020. Among the postpartum women, 23 patients were excluded due to late-onset dyspnea (n=20: >48 h after delivery) or the presence of PTE (n=3). A total of 86 patients were divided into three groups (27 postpartum women [postpartum group], 19 women with PTE [PTE group], and 40 women without PTE [non-PTE group]). Quantitation was applied to a decreased LIM value (LIM5; defined as <5 HU) and the relative value of LIM5 to whole LIM volume (%LIM5). LIM defects were classified into five patterns (0 = none, 1 = wedge-shaped, 2 = reticular/liner, 3 = diffuse granular/patchy, 4 = massive defects) based on a consensus between two readers.

RESULTS

There were significant differences in the LIM5 and %LIM5 values among the three groups. The LIM5 and %LIM5 were largest in the PTE group, and postpartum women showed intermediate values between the non-PTE and PTE groups. Wedge-shaped defects were prominent in the PTE group, and diffuse granular/patchy defect was a typical feature in the postpartum group.

CONCLUSION

Postpartum women with dyspnea showed granular/patchy defects on DECT with a median quantitative value between the PTE and non-PTE groups.

Nontrombotic Pulmonary Embolism: Different Etiology, Same Significant Consequences

Nontrombotic pulmonary embolism represents the embolization of different types of materials (cells, organisms, gas, foreign material) into pulmonary circulation. The disease is uncommon, and clinical presentation together with laboratory findings are nonspecific. Its pathology is usually misdiagnosed based on imaging findings as pulmonary thromboembolism, but the correct diagnosis is essential because different therapeutic approaches are required. In this context, knowledge of the risk factors associated with nontrombotic pulmonary embolism and specific clinical symptoms is fundamental. Our objective was to discuss the specific features of the most common etiologies of nontrombotic pulmonary embolism, gas, fat, amniotic fluid, sepsis and tumors, to provide assistance for a rapid and correct diagnosis. Because the most common etiologies are iatrogenic, knowledge of the risk factors could be an important tool for prevention or rapid treatment if the disease develops during different procedures. The diagnosis of nontrombotic pulmonary embolisms represent a laborious challenge, and endeavors should be made to prevent development and increase awareness of this disease.

Application of the RCOG Risk Assessment Model for Evaluating Postpartum Venous Thromboembolism in Chinese Women: A Case-Control Study

BACKGROUND Since China has not yet constructed its own risk assessment model (RAM) for pregnancy-related venous thromboembolism (VTE), more and more hospitals use the RCOG RAM for VTE risk prediction. However, the RCOG RAM was established based on Western populations, and its applicability in China is still uncertain. Thus, we aimed to evaluate the validity of the RCOG RAM in predicting postpartum VTE in Chinese maternity. MATERIAL AND METHODS This retrospective case-control study was conducted at the International Peace Maternity and Child Health Hospital (IPMCHH) from June 2016 to June 2020. The VTE group consisted of 38 women with postpartum VTE. For each VTE patient, 4 women without VTE who gave birth on the same day were randomly selected as the control group (n=152). The receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) were used to evaluate the discrimination, accuracy, and validity of the RCOG RAM. Univariable analysis and multivariable logistic regression analysis were used to identify other related factors for postpartum VTE. RESULTS Compared with the low-risk group, the risk of VTE was 9.75-fold greater in the intermediate-risk group, and 90.00-fold greater in the high-risk group. The area under curve (AUC) of the model was 0.828 (95% CI: 0.762-0.894), with a score of 2 as its best cut-off value, which exactly matched the criterion recommended by the RCOG guidelines for pharmacological thromboprophylaxis. The calibration curves and DCA of the model also showed good accuracy. In addition to the factors included in the RCOG RAM, glucocorticoid therapy during pregnancy (adjusted OR=6.72, 95% CI: 1.56-28.91) and previous use of IUD (adjusted OR=7.11, 95% CI: 1.45-34.93) were associated with increased risk of postpartum VTE. CONCLUSIONS The RCOG RAM was found to be effective in predicting postpartum VTE, and has certain guiding significance for postpartum thromboprophylaxis in China.

Postoperative Thyroid Storm After Evacuation of a Complete Hydatidiform Mole: A Case Report

Gestational trophoblastic disease can lead to excess thyroid hormone release and rarely, thyroid storm. We present a case of complete molar pregnancy with hyperthyroidism that was not identified or treated before surgical evacuation of uterine contents. Untreated hyperthyroidism preoperatively led to unanticipated thyroid storm immediately after emergence from anesthesia. It is important for anesthesia providers to recognize the link between gestational trophoblastic disease and thyrotoxicosis, and appreciate the severe consequences than can occur if left untreated. Anesthesia providers should strongly consider preoperative consultation and treatment. Being prepared to treat intraoperative symptoms and thyroid storm is paramount.

Successful treatment of amniotic fluid embolism complicated by disseminated intravascular coagulation with rivaroxaban: A case report

RATIONALE

An amniotic fluid embolism (AFE) is a rare, lethal syndrome that is commonly associated with disseminated intravascular coagulation (DIC). Anticoagulation therapy is the most important strategy to inhibit excessive activation of the coagulation cascade in patients with AFE and DIC. At present, treatment of AFE with rivaroxaban has not been reported.

PATIENT CONCERNS

We report a 37-year-old woman (gravida 2, para 1) at 39 weeks' gestation with irregular contractions of the uterus was admitted to the obstetrical department. Ten minutes after the spontaneous rupture of the membranes, the patient complained of dyspnea and dysphoria and exhibited cyanosis of her lips. The patient's blood pressure decreased and heart rate increased rapidly, and 2100 mL of unclotted blood flowed from her vagina within 1 hour. Her platelet count dropped to 21 × 10/L, and the results from routine coagulation tests, and D-dimer and fibrin degradation product tests were obviously abnormal.

DIAGNOSES

According to the current research consensus, AFE with DIC should be considered immediately when sudden cardiovascular collapse occurs around the time of labor and delivery, followed by the development of coagulopathy and hemorrhage.

INTERVENTIONS

In addition, the variety of supportive treatments, rivaroxaban was used in anticoagulant therapy.

OUTCOMES

At follow-up 30 and 60 days, there were no complaints of discomfort or abnormal laboratory assays. The patient recovered completely.

LESSONS

This case highlights that rivaroxaban, as a direct inhibitor of activated factor Xa, demonstrates a good therapeutic efficacy for treating AFE with DIC.

Resuscitation of the Pregnant Patient

Many health care providers lack familiarity with maternal physiologic changes and the distinctive underlying etiology of cardiac arrest in pregnancy. Knowledge of what changes are expected in pregnancy and an understanding of how to adapt clinical practice is essential for the care of the pregnant woman in the emergency department. Amniotic fluid embolism should be recognized as a rare cause of cardiac arrest in pregnancy, characterized by the triad of cardiovascular collapse, hypoxic respiratory failure, and coagulopathy. Cardiopulmonary resuscitation should follow standard AHA ACLS guidelines. Resuscitative hysterotomy may be attempted to restore perfusion to both mother and fetus.

Amniotic fluid embolism and spontaneous hepatic rupture during uncomplicated pregnancy: a case report and literature review

Amniotic fluid embolism (AFE) and spontaneous hepatic rupture both are extremely rare complications of pregnancy that can be fatal to mother and/or child. AFE is characterized by a sudden collapse of the cardiovascular system, a change in mental status, and disseminated intravascular coagulation (DIC), occurring immediately during labor, delivery, or postpartum, caused by the inflow of amniotic components into the maternal circulation. Spontaneous hepatic rupture during pregnancy which is most often occurs alongside hypertensive disorders, eclampsia, or HELLP syndrome. We report on the case of a 28-year-old woman (G3P2) who is suffering from AFE and spontaneous hepatic rupture, without history of hypertensive disorders, preeclampsia/eclampsia, or HELLP syndrome, and she died suddenly after delivering of a severe asphyxial neonate within 1 h with postpartum of hepatic rupture and massive hemorrhage. The lack of typical clinical signs and symptoms resulted to the difficulty of early diagnosis. If AFE and hepatic rupture is highly suspected in a pregnant patient, a collaborative multidisciplinary approach is mandatory. Pregnancy women is simultaneously complicated in amniotic fluid embolism and spontaneous hepatic rupture, similar cases are infrequent in the literature, which is reviewed in this report, explore the pathophysiological changes, we hope that can be helpful for the prevention, diagnosis and treatment of similar cases.