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Vuong ADB, Pham TH, Bui VH, Nguyen XT, Trinh NB, Nguyen YON, Le DKT, Nguyen PN. Successfully conservative management of the uterus in acute pulmonary embolism during cesarean section for placenta previa: a case report from Tu Du Hospital, Vietnam and literature review. Int J Emerg Med 2024; 17:14. [PMID: 38287235 PMCID: PMC10823749 DOI: 10.1186/s12245-024-00587-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 01/12/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Cardiopulmonary collapse is a catastrophic event in cesarean section, which leads to adverse outcomes for both the mother and the fetus. Pulmonary embolism is one of the rare etiologies of this entity. We herein reported the successful management of acute embolism pulmonary associated with cesarean delivery on a healthy pregnant woman at our tertiary referral hospital. CASE PRESENTATION A full-term pregnant woman hospitalized for planned cesarean delivery due to placenta previa without cardiorespiratory diseases. She was scheduled uneventfully for a planned cesarean section. After placental delivery, the patient spontaneously fell into cardiopulmonary collapse and her vital signs deteriorated rapidly. The obstetricians promptly completed the cesarean section and performed all procedures to prevent the PPH and preserve the uterus. At the same time, the anesthesiologists continued to carry out advanced heart-lung resuscitation in order to control her vital signs. After surgery, the multidisciplinary team assessed the patient and found a thrombus in her pulmonary circulation. Therefore, the patient was managed with therapeutic anticoagulation. The patient recovered in good clinical condition and was discharged after 2 weeks without any complications. CONCLUSIONS The diagnosis of acute pulmonary embolism is extremely difficult due to uncommon occurrence, sudden onset, and non-specific presentation. Awareness of this life-threatening pathology during cesarean delivery should be raised. Interdisciplinary assessment must be essentially established in this life-threatening condition. After the whole conventional management, uterine conservation may be acceptable where applicable. Further data is required to encourage this finding.
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Affiliation(s)
- Anh Dinh Bao Vuong
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam
| | - Thanh Hai Pham
- Tu Du Clinical Research Unit (TD-CRU), Tu Du Hospital, Ho Chi Minh City, Vietnam
| | - Van Hoang Bui
- Integrated Planning Room, Tu Du Hospital, Ho Chi Minh City, Vietnam
| | - Xuan Trang Nguyen
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam
| | - Ngoc Bich Trinh
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam
| | - Yen Oanh Ngoc Nguyen
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam
| | - Dang Khoa Tran Le
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam
| | - Phuc Nhon Nguyen
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam.
- Tu Du Clinical Research Unit (TD-CRU), Tu Du Hospital, Ho Chi Minh City, Vietnam.
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Hinkelbein J, Andres J, Böttiger BW, Brazzi L, De Robertis E, Einav S, Gwinnutt C, Kuvaki B, Krawczyk P, McEvoy MD, Mertens P, Moitra VK, Navarro-Martinez J, Nunnally ME, O Connor M, Rall M, Ruetzler K, Schmitz J, Thies K, Tilsed J, Zago M, Afshari A. Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery. Eur J Trauma Emerg Surg 2023; 49:2031-2046. [PMID: 37430174 PMCID: PMC10520188 DOI: 10.1007/s00068-023-02271-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council guidelines. MATERIAL AND METHODS The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment, and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches. RESULTS This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage, resuscitative endovascular balloon occlusion and resuscitative thoracotomy, pericardiocentesis, needle decompression, and thoracostomy. CONCLUSIONS Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition, and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well-organised team using crew resource management, but also on an institutional safety culture embedded in everyday practice through continuous education, training, and multidisciplinary co-operation.
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Affiliation(s)
- Jochen Hinkelbein
- Department of Anaesthesiology, Intensive Care Medicine and Emergency Medicine, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany.
| | - Janusz Andres
- Department of Anaesthesiology and Intensive Therapy, Jagiellonian University Medical College, Krakow, Poland
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, Medical Faculty, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Luca Brazzi
- The Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Edoardo De Robertis
- The Division of Anaesthesia, Analgesia and Intensive Care, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Sharon Einav
- The Intensive Care Unit, Shaare Zedek Medical Center, Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Carl Gwinnutt
- The Department of Anaesthesia, Salford Royal NHS Foundation Trust, Salford, UK
| | - Bahar Kuvaki
- The Department of Anesthesiology and Reanimation, Dokuz Eylül University, İzmir, Turkey
| | - Pawel Krawczyk
- The Department of Anesthesiology and Intensive Care Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Matthew D McEvoy
- The Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pieter Mertens
- The Department of Anaesthesiology, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium
| | - Vivek K Moitra
- Division of Critical Care Anesthesiology, The Department of Anesthesiology, Columbia University, Columbia, NY, USA
| | - Jose Navarro-Martinez
- The Anesthesiology Department, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISAB), Biomedical Research (ISABIAL), Alicante, Spain
| | - Mark E Nunnally
- The Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Michael O Connor
- The Department of Anesthesiology & Critical Care, University of Chicago, Chicago, IL, USA
| | - Marcus Rall
- The Institute for Patient Safety and Simulation Team Training InPASS, Reutlingen, Germany
| | - Kurt Ruetzler
- The Departments of General Anesthesiology and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jan Schmitz
- Department of Anaesthesiology and Intensive Care Medicine, Medical Faculty, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Karl Thies
- The Department of Anaesthesiology and Critical Care, EvKB, OWL University Medical Center, Bielefeld University, Campus Bielefeld-Bethel, Bethel, Germany
| | - Jonathan Tilsed
- The Department of Surgery, Hull University Teaching Hospitals, Hull, UK
| | - Mauro Zago
- General & Emergency Surgery Division, The Department of Surgery, A. Manzoni Hospital, Milan, Italy
| | - Arash Afshari
- The Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Denmark
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3
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Hinkelbein J, Andres J, Böttiger BW, Brazzi L, De Robertis E, Einav S, Gwinnutt C, Kuvaki B, Krawczyk P, McEvoy MD, Mertens P, Moitra VK, Navarro-Martinez J, Nunnally ME, O'Connor M, Rall M, Ruetzler K, Schmitz J, Thies K, Tilsed J, Zago M, Afshari A. Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery. Eur J Anaesthesiol 2023; 40:724-736. [PMID: 37218626 DOI: 10.1097/eja.0000000000001813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
INTRODUCTION Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council (ERC) guidelines. MATERIAL AND METHODS The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches. RESULTS This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage (OCCM), resuscitative endovascular balloon occlusion (REBOA) and resuscitative thoracotomy, pericardiocentesis, needle decompression and thoracostomy. CONCLUSION Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well organised team using crew resource management but also on an institutional safety culture embedded in everyday practice through continuous education, training and multidisciplinary co-operation.
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Affiliation(s)
- Jochen Hinkelbein
- From the University Department of Anaesthesiology, Intensive Care Medicine and Emergency Medicine, Johannes Wesling Klinikum Minden, University Hospital Ruhr-University Bochum, Minden, Germany (JH), Department of Anaesthesiology and Intensive Care Medicine, Medical Faculty and University Hospital of Cologne, Cologne, Germany (BWB, JS), Department of Anaesthesiology and Intensive Therapy, Jagiellonian University Medical College, Krakow, Poland (JA), Department of Surgical Sciences, University of Turin, Turin (LB), Division of Anaesthesia, Analgesia and Intensive Care, Department of Medicine and Surgery, University of Perugia, Italy (EdR), Intensive Care Unit, Shaare Zedek Medical Center and Hebrew University Faculty of Medicine, Jerusalem, Israel (SE), Department of Anaesthesia, Salford Royal NHS Foundation Trust, Salford, UK (CG), Department of Anesthesiology and Reanimation, Dokuz Eylül University, İzmir, Turkey (BK), Department of Anesthesiology and Intensive Care Medicine, Jagiellonian University Medical College, Krakow, Poland (PK), Department of Anaesthesiology, Antwerp University Hospital, Edegem, Belgium (PM), Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee (MDM), Division of Critical Care Anesthesiology, Department of Anesthesiology, Columbia University, New York, USA (VKM), Anesthesiology Department, Dr Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISAB), and Biomedical Research (ISABIAL), Alicante, Spain (JN-M), Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York (MEN), Department of Anesthesiology & Critical Care, University of Chicago, Illinois, USA (MO'C), Institute for Patient Safety and Simulation Team Training InPASS, Reutlingen, Germany (MR), Departments of General Anesthesiology and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA (KR), Department of Anaesthesiology and Critical Care, EvKB, OWL University Medical Center, Bielefeld University, Campus Bielefeld-Bethel, Germany (KT), Department of Surgery, Hull University Teaching Hospitals, Hull, UK (JT), General & Emergency Surgery Division, Department of Surgery, A. Manzoni Hospital, Milan, Italy (MZ) and Department of Paediatric and Obstetric Anaesthesia, Juliane Marie Centre, Rigshospitalet, Denmark and Department of Clinical Medicine, University of Copenhagen, Denmark (AA)
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Muacevic A, Adler JR, Sousa JE, Carmezim I, Gomes A. Thrombolytic Dilemma: A Case Report of Early Puerperium Ischemic Stroke Treated With Intravenous Thrombolysis. Cureus 2023; 15:e33204. [PMID: 36733555 PMCID: PMC9888589 DOI: 10.7759/cureus.33204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2022] [Indexed: 01/03/2023] Open
Abstract
A 25-year-old woman was admitted to the obstetrics ward when presented with a sudden onset of expressive aphasia and minor right facial palsy 48 hours after forceps-assisted delivery. The intrahospital emergency team was immediately mobilized. The patient had a blood pressure (BP) of 119/79 mmHg, heart rate of 114 bpm, O2 saturation of 97%, and blood glucose level of 136 mg/dL. Trauma and toxic exposure were ruled out. A rapid EKG was performed with no significant changes. Assuming an acute stroke, the patient immediately underwent brain CT (approximately 15 minutes after the beginning of the symptoms), which revealed no signs of hemorrhage, an ischemic area, or masses. Brain CT angiography was then performed; however, no major brain artery obstruction was found. With brain hemorrhage ruled out and persistent neurologic deficits, the case was discussed between the emergency team doctor and the patient's obstetrician, and intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator (rt-PA) was started approximately 45 minutes after the onset of symptoms. After treatment completion, the patient had a complete resolution of the neurological deficits. The patient remained under strict observation at the acute stroke unit (ASU), and no secondary brain hemorrhage or post-partum-related complications were noted.
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Girona M, Säly C, Makaloski V, Baumgartner I, Schindewolf M. Catheter-Directed Thrombolysis for Postpartum Deep Venous Thrombosis. Front Cardiovasc Med 2022; 9:814057. [PMID: 35557538 PMCID: PMC9087264 DOI: 10.3389/fcvm.2022.814057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/16/2022] [Indexed: 11/30/2022] Open
Abstract
Venous thromboembolism is a major concern during pregnancy as well as in the postpartum period. In acute proximal deep venous thrombosis, endovascular recanalization with locally administered thrombolytic agents has evolved as therapeutic alternative to anticoagulation alone. However, data on the bleeding risk of thrombolysis in the postpartum period is limited. We addressed the key clinical question of safety outcomes of catheter-directed thrombolysis (CDT) in the peri- and postpartum period. Therefore, we performed a non-exhaustive literature review and illustrated the delicate management of a patient with postpartum acute iliofemoral thrombosis treated with CDT and endovascular revascularization with thrombectomy, balloon angioplasty and stenting.
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Affiliation(s)
- Miguel Girona
- Division of Angiology, Swiss Cardiovascular Center, University Hospital of Bern (Inselspital), University of Bern, Bern, Switzerland
| | - Christoph Säly
- Department of Medicine I, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Vladimir Makaloski
- Department of Cardiovascular Surgery, Swiss Cardiovascular Center, University Hospital of Bern (Inselspital), University of Bern, Bern, Switzerland
| | - Iris Baumgartner
- Division of Angiology, Swiss Cardiovascular Center, University Hospital of Bern (Inselspital), University of Bern, Bern, Switzerland
| | - Marc Schindewolf
- Division of Angiology, Swiss Cardiovascular Center, University Hospital of Bern (Inselspital), University of Bern, Bern, Switzerland
- *Correspondence: Marc Schindewolf,
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Abstract
PURPOSE OF REVIEW Cerebrovascular disorders during pregnancy and puerperium are uncommon but potentially serious entities. This review aims to provide guidance on the diagnosis and management of these diseases, according to the most recent findings. RECENT FINDINGS Proteinuria is no longer a mandatory criterion for the diagnosis of preeclampsia. Favourable long-term foetal and maternal outcomes are achieved in most patients with ruptured cerebral arterial malformations during pregnancy receiving interventional treatment prior to delivery. Despite the recent recommendations, physicians still hesitate to administer thrombolysis in pregnant women. In women with a history of cerebral venous thrombosis, prophylaxis with low molecular weight heparin during pregnancy and puerperium is associated with lower rates of recurrent thrombotic events and miscarriage. SUMMARY Hypertensive disorders of pregnancy are a continuum of failure of autoregulation mechanisms that may lead to eclampsia, posterior reversible encephalopathy syndrome, reversible cerebral vasoconstriction syndrome and stroke. MRI is the preferred imaging modality of choice. In the absence of specific contraindications, treatment of cerebrovascular complications should not be withheld from pregnant women, including reperfusion therapies in acute ischemic stroke and treatment of ruptured cerebral aneurysms. Previous history of stroke alone does not contraindicate future pregnancy, but counselling and implementation of prevention strategies are needed.
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Affiliation(s)
- Mónica Santos
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria - CHULN
| | - Diana Aguiar de Sousa
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria - CHULN
- Faculdade de Medicina, Universidade de Lisboa
- Instituto de Medicina Molecular João Lobo Antunes, Lisbon, Portugal
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Systemic Thrombolysis for Treatment of Postpartum Saddle Embolism Complicated by Postpartum Hemorrhage: A Case Report and Brief Literature Review. Case Rep Obstet Gynecol 2021; 2021:5553296. [PMID: 34306779 PMCID: PMC8263235 DOI: 10.1155/2021/5553296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 05/01/2021] [Accepted: 06/14/2021] [Indexed: 11/26/2022] Open
Abstract
Venous thromboembolic events (VTE), specifically pulmonary embolisms, account for a significant portion of maternal morbidity and mortality. Due to the procoagulant physiological changes that occur, pregnancy and the postpartum period are known risk factors for thromboembolic events. The risk is greatest during the first-week postpartum and remains elevated for up to six weeks as compared to the general population. Treatment guidelines regarding the use of thrombolytics for massive pulmonary embolism occurring in pregnancy and the postpartum are not well established. In nonpregnant populations, thrombolytic agents are well known to decrease the mortality in the setting of a massive pulmonary embolism. However, in the absence of management guidelines, thrombolysis in pregnancy remains guided by case reports and case series. We present a case of a massive pulmonary embolism (PE) causing hemodynamic instability during the postpartum period treated with tissue plasminogen activator (tPA). The case was complicated by delayed postpartum hemorrhage successfully managed with the uterotonic methylergometrine. The patient was started on oral anticoagulation and continued for six months without recurrent VTE. Our case demonstrates a rare occurrence of a saddle embolism after a vaginal delivery within the first postpartum week which was successfully managed with the use of systemic thrombolysis and minimal intervention to manage the iatrogenic delayed postpartum hemorrhage. To the authors' knowledge, no other similar case report exists. This case highlights the need to develop guidelines for the use of thrombolysis in mothers who present with massive pulmonary embolus and a noninvasive means to manage adverse bleeding events in the puerperium.
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Rodriguez D, Jerjes-Sanchez C, Fonseca S, Garcia-Toto R, Martinez-Alvarado J, Panneflek J, Ortiz-Ledesma C, Nevarez F. Thrombolysis in massive and submassive pulmonary embolism during pregnancy and the puerperium: a systematic review. J Thromb Thrombolysis 2021; 50:929-941. [PMID: 32347509 DOI: 10.1007/s11239-020-02122-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Thrombolysis in high-risk pulmonary embolism (PE) patients is recommended worldwide; however, the evidence for thrombolysis during pregnancy and the immediate puerperium remains unclear. We conducted a systematic review from 1950 to 2019 through PubMed, Ovid/Willey, and Cochrane Library to assess the safety and effectiveness of thrombolysis during pregnancy and the immediate puerperium. Additionally, we characterized the clinical presentation, risk stratification, and diagnostic approach. We have communicated our results according to the PRISMA statement. We collected 141 records and, after critical assessment, included 47 case reports of 54 patients, including 43 and 11 patients during pregnancy and puerperium, respectively. During pregnancy, alteplase was the most frequent systemic thrombolytic agent used (67%), but only nine patients received the approved FDA regimen. With catheter-directed thrombolysis, low-dose thrombolytics and fragmentation were the most common regimens. Major bleeding occurred in 18% of cases, but there was no intracranial bleeding. One maternal death occurred secondary to refractory cardiogenic shock. Fetal mortality was 20%. During the immediate puerperium, nine patients received "off-label" first-, second-, and third-generation thrombolytic regimens, and four cases underwent catheter-directed thrombolysis. We observed nine major bleeding events, seven of which were from the uterine location and none of which were intracranial. In conclusion, overall, these data do not suggest prohibitive risk associated with thrombolysis for PE in pregnancy. Management of massive and high-risk submassive PE in pregnancy should be individualized to each patient. In the data presented, no fatal bleeding or intracranial bleeding was observed. Finally, future efforts should systematically collect and report data on high-risk PE in pregnancy and peripartum patients to improve the evidence-base clinical practice.
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Affiliation(s)
- David Rodriguez
- Escuela de Medicina y Ciencias de La Salud, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico
- Centro de Investigacion Biomedica del Hospital Zambrano Hellion, TecSalud, San Pedro Garza García, Nuevo Leon, Mexico
- Instituto de Cardiología y Medicina Vascular, TecSalud, San Pedro Garza García, Nuevo Leon, Mexico
| | - Carlos Jerjes-Sanchez
- Escuela de Medicina y Ciencias de La Salud, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico.
- Centro de Investigacion Biomedica del Hospital Zambrano Hellion, TecSalud, San Pedro Garza García, Nuevo Leon, Mexico.
- Instituto de Cardiología y Medicina Vascular, TecSalud, San Pedro Garza García, Nuevo Leon, Mexico.
- Hospital Zambrano Hellion, Batallón de San Patricio 112, Real San Agustin, San Pedro Garza Garcia, Nuevo Leon, 66278, Mexico.
| | - Sugely Fonseca
- Internal Medicine, Hospital San José, TecSalud, Nuevo Leon, Monterrey, Mexico
| | | | | | | | - Claudia Ortiz-Ledesma
- Escuela de Medicina y Ciencias de La Salud, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico
| | - Francisco Nevarez
- Escuela de Medicina y Ciencias de La Salud, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico
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Hanson R, Brown P, Temple-Cooper M, Hoyt M. Puerperium Stroke and Subsequent Tissue-Type Plasminogen Activator-Induced Hemorrhage: A Case Report. A A Pract 2021; 15:e01459. [PMID: 33955867 DOI: 10.1213/xaa.0000000000001459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a case of ischemic stroke in an apparently healthy 35-year-old gravida 2 para 1 who was treated with tissue-type plasminogen activator (tPA) 9 hours after vaginal delivery that resulted in severe hemorrhage. Limited data suggest use of thrombolytics in pregnancy is safe, but there is a paucity of evidence assessing their use immediately postpartum. We describe successful combination of tPA with endovascular mechanical thrombectomy (EMT) for treatment of postpartum stroke, which was followed by extensive uterine bleeding.
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Affiliation(s)
| | - Peter Brown
- Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mary Temple-Cooper
- Department of Pharmacy, Hillcrest Hospital, Cleveland Clinic Health System, Mayfield Heights, Ohio
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Reperfusion Therapy for Acute Stroke in Pregnant and Post-Partum Women: A Canadian Survey. Can J Neurol Sci 2020; 48:344-348. [PMID: 32959754 DOI: 10.1017/cjn.2020.207] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND/OBJECTIVE A Canadian Stroke Best Practices consensus statement on Acute Stroke Management during pregnancy was published in 2018. The state of individual practice, however, is unknown. METHODS A survey on treatment of acute stroke in pregnant and post-partum women was distributed via the Canadian Stroke Consortium email list. Descriptive statistics (frequencies and proportions) were calculated for demographic and response variables and free-text responses were coded for thematic content. RESULTS Thirty-five participants completed the survey; 12 had experience with intravenous tissue plasminogen activator (IV-tPA), endovascular therapy (EVT), or both in pregnant patients. None had treatment-related complications. The majority (92%) of those who had not yet encountered the issue in practice expressed some reservation about giving IV-tPA to an otherwise eligible pregnant woman. In a theoretical scenario where an otherwise eligible pregnant woman was a candidate for both IV-tPA and EVT, 58% of respondents would have opted for EVT alone. Amongst this cohort comprised mainly of stroke sub-specialists, more than a third had treated pregnant patients with reperfusion therapy. CONCLUSIONS The reported safety experience with both IV-tPA and EVT was reassuring. Overall, there was a hesitancy towards use of IV-tPA in pregnancy that is discordant with the recent consensus statement. Possible barriers to uptake identified through thematic analysis were concerns regarding risks of bleeding in the pregnant patient, presence of EVT as a perceived alternative, and the need for express consent from the patient and family.
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Farooque U, Cheema O, Karimi S, Pillai B, Liaquat MT. Postpartum Ischemic Stroke: A Rare Case. Cureus 2020; 12:e9975. [PMID: 32983677 PMCID: PMC7510514 DOI: 10.7759/cureus.9975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The risk of stroke is increased during pregnancy and the postpartum period. It can lead to significant maternal morbidity and mortality. The physiologically mediated hemodynamic changes in circulation and vascular tissue, and the increased coagulability account for this increased risk of stroke. Pregnancy-related strokes can be hemorrhagic or ischemic. We present a rare case of postpartum ischemic stroke. A 25-year-old female with no known comorbidities and a history of cesarean section 10 days back presented with a right-sided weakness and sensory loss for one day. An MRI of the head revealed a large area of restricted diffusion on diffusion-weighted 1 (DW1) image in the left parietal region with comparable low signals on apparent diffusion coefficient (ADC) map and a small area of blooming suggesting hemorrhage on susceptibility-weighted 1 (SW1) image. This area appeared hypointense on T1 and hyperintense on fluid-attenuated inversion recovery (FLAIR) and T2 images. These findings suggested acute ischemic infarction. She was started on antiplatelet therapy, and subsequently, her weakness improved. She was discharged upon improvement in her symptoms and was asked to follow up in the outpatient department. Numerous studies have shown an increased risk of ischemic stroke in the immediate postpartum period in women who undergo a cesarean section. Thus, we conclude that clinicians should be aware of this complication and high-risk patients should be identified and monitored more aggressively in their immediate postpartum period.
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Affiliation(s)
- Umar Farooque
- Neurology, Dow University of Health Sciences, Karachi, PAK
| | - Omer Cheema
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Sundas Karimi
- General Surgery, Combined Military Hospital, Karachi, PAK
| | - Bharat Pillai
- Neurology, Amrita Institute of Medical Sciences, Kochi, IND
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Abstract
Ischemic stroke (IS) and hemorrhagic stroke (HS) can be devastating complications during pregnancy and the puerperium that are thought to occur in approximately 30 in 100,000 pregnancies. In high-risk groups, such as women with preeclampsia, the incidence of both stroke subtypes, combined, is up to 6-fold higher than in pregnant women without these disorders. IS or HS may present in young women with atypical symptoms including headache, seizure, extremity weakness, dizziness, nausea, behavioral changes, and visual symptoms. Obstetric anesthesiologists who recognize these signs and symptoms of pregnancy-related stroke are well positioned to facilitate timely care. Acute stroke of any type is an emergency that should prompt immediate coordination of care between obstetric anesthesiologists, stroke neurologists, high-risk obstetricians, nurses, and neonatologists. Historically, guidelines have not addressed the unique situation of maternal stroke, and pregnant women have been excluded from the large stroke trials. More recently, several publications and professional societies have highlighted that pregnant women suspected of having IS or HS should be evaluated for the same therapies as nonpregnant women. Vaginal delivery is generally preferred unless there are obstetric indications for cesarean delivery. Neuraxial analgesia and anesthesia are frequently safer than general anesthesia for cesarean delivery in the patient with a recent stroke. Potential exceptions include therapeutic anticoagulation or intracranial hypertension with risk of herniation. General anesthesia may be appropriate when cesarean delivery will be combined with intracranial neurosurgery.
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Affiliation(s)
- Eliza C Miller
- From the Department of Neurology, Division of Stroke and Cerebrovascular Disease, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Lisa Leffert
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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13
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Roeder HJ, Lopez JR, Miller EC. Ischemic stroke and cerebral venous sinus thrombosis in pregnancy. HANDBOOK OF CLINICAL NEUROLOGY 2020; 172:3-31. [PMID: 32768092 PMCID: PMC7528571 DOI: 10.1016/b978-0-444-64240-0.00001-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Maternal ischemic stroke and cerebral venous sinus thrombosis (CVST) are dreaded complications of pregnancy and major contributors to maternal disability and mortality. This chapter summarizes the incidence and risk factors for maternal arterial ischemic stroke (AIS) and CVST and discusses the pathophysiology of maternal AIS and CVST. The diagnosis, treatment, and secondary preventive strategies for maternal stroke are also reviewed. Special populations at high risk of maternal stroke, including women with moyamoya disease, sickle cell disease, HIV, thrombophilia, and genetic cerebrovascular disorders, are highlighted.
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Affiliation(s)
- Hannah J Roeder
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Jean Rodriguez Lopez
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Eliza C Miller
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, United States.
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14
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Kang H, Shin YM, Kim SM, Kim Y, Dalla Vecchia LA, Ho KM. Multidisciplinary team approach on massive postpartum pulmonary thromboembolism: experience from three cases. J Thorac Dis 2019; 11:1690-1696. [PMID: 31179115 DOI: 10.21037/jtd.2019.02.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Hyeran Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungbuk National University College of Medicine and Chungbuk National University Hospital, Cheongju-si, Republic of Korea
| | - Yoon Mi Shin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungbuk National University College of Medicine and Chungbuk National University Hospital, Cheongju-si, Republic of Korea
| | - Sang Min Kim
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University College of Medicine and Chungbuk National University Hospital, Cheongju-si, Republic of Korea
| | - Yook Kim
- Department of Radiology, Chungbuk National University College of Medicine and Chungbuk National University Hospital, Cheongju-si, Republic of Korea
| | | | - Kwok Ming Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Australia
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15
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Ladhani NNN, Swartz RH, Foley N, Nerenberg K, Smith EE, Gubitz G, Dowlatshahi D, Potts J, Ray JG, Barrett J, Bushnell C, Bal S, Chan WS, Chari R, El Amrani M, Gandhi S, Hill MD, James A, Jeerakathil T, Jin A, Kirton A, Lanthier S, Lausman A, Leffert LR, Mandzia J, Menon B, Pikula A, Poppe A, Saposnik G, Sharma M, Bhogal S, Smitko E, Lindsay MP. Canadian Stroke Best Practice Consensus Statement: Acute Stroke Management during pregnancy. Int J Stroke 2018; 13:743-758. [PMID: 30021491 DOI: 10.1177/1747493018786617] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The Canadian Stroke Best Practice Consensus Statement Acute Stroke Management during Pregnancy is the second of a two-part series devoted to stroke in pregnancy. The first part focused on the unique aspects of secondary stroke prevention in a woman with a prior history of stroke who is, or is planning to become, pregnant. This document focuses on the management of a woman who experiences an acute stroke during pregnancy. This consensus statement was developed in recognition of the need for a specifically tailored approach to the management of this group of patients in the absence of any broad-based, stroke-specific guidelines or consensus statements, which do not exist currently. The foundation for the development of this document was the concept that maternal health is vital for fetal well-being; therefore, management decisions should be based first on the confluence of two clinical considerations: (a) decisions that would be made if the patient wasn't pregnant and (b) decisions that would be made if the patient hadn't had a stroke, then nuanced as needed. While empirical research in this area is limited, this consensus document is based on the best available literature and guided by expert consensus. Issues addressed in this document include initial emergency management, diagnostic imaging, acute stroke treatment, the management of hemorrhagic stroke, anesthetic management, post stroke management for women with a stroke in pregnancy, intrapartum considerations, and postpartum management. These statements are appropriate for healthcare professionals across all disciplines and system planners to ensure pregnant women who experience a stroke have timely access to both expert neurological and obstetric care.
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Affiliation(s)
- Noor Niyar N Ladhani
- 1 Sunnybrook Health Sciences Centre, Toronto, Canada.,2 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto, Toronto, Canada
| | - Richard H Swartz
- 1 Sunnybrook Health Sciences Centre, Toronto, Canada.,3 Faculty of Medicine (Neurology), University of Toronto, Toronto, Canada
| | - Norine Foley
- 4 Department of Foods and Nutrition, Western University, London, Ontario, Canada.,5 workHORSE Consulting Group, London, Ontario, Canada
| | - Kara Nerenberg
- 6 Department of Medicine, University of Calgary, Calgary, Canada
| | - Eric E Smith
- 7 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,8 Calgary Stroke Program, Calgary, Canada
| | - Gord Gubitz
- 9 Queen Elizabeth II Health Sciences Centre, Halifax, Canada.,10 Department of Medicine (Neurology), Dalhousie University, Halifax, Canada
| | | | - Jayson Potts
- 12 Department of Obstetric General Internal Medicine, British Columbia Women's Hospital, Vancouver, Canada
| | - Joel G Ray
- 2 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto, Toronto, Canada.,13 Department of Maternal-Fetal Medicine, St. Michael's Hospital, Toronto, Canada
| | - Jon Barrett
- 1 Sunnybrook Health Sciences Centre, Toronto, Canada.,2 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto, Toronto, Canada
| | - Cheryl Bushnell
- 14 Wake Forest Baptist Stroke Center, Wake Forest Baptist Health, Winston Salem, NC, USA
| | - Simerpreet Bal
- 7 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Wee-Shian Chan
- 12 Department of Obstetric General Internal Medicine, British Columbia Women's Hospital, Vancouver, Canada
| | - Radha Chari
- 15 Faculty of Medicine & Dentistry, Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Canada
| | - Meryem El Amrani
- 16 Centre hospitalier de l'Université de Montréal, Montreal, Canada
| | - Shital Gandhi
- 2 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto, Toronto, Canada.,17 Sinai Health System, Toronto, Canada
| | - Michael D Hill
- 7 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,8 Calgary Stroke Program, Calgary, Canada
| | - Andra James
- 18 Division of Maternal-Fetal Medicine, Duke University, Durham, NC, USA
| | - Thomas Jeerakathil
- 19 Department of Medicine & Dentistry (Neurosciences), University of Alberta, Edmonton, Canada
| | - Albert Jin
- 20 Department of Medicine, Queen's University, Kingston, Canada
| | - Adam Kirton
- 7 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,8 Calgary Stroke Program, Calgary, Canada
| | - Sylvain Lanthier
- 16 Centre hospitalier de l'Université de Montréal, Montreal, Canada
| | - Andrea Lausman
- 2 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto, Toronto, Canada.,13 Department of Maternal-Fetal Medicine, St. Michael's Hospital, Toronto, Canada
| | - Lisa Rae Leffert
- 21 Department of Obstetric Anesthesia, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer Mandzia
- 22 Department of Clinical Neurological Sciences, Western University, London, Canada
| | - Bijoy Menon
- 7 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,8 Calgary Stroke Program, Calgary, Canada
| | - Aleksandra Pikula
- 3 Faculty of Medicine (Neurology), University of Toronto, Toronto, Canada.,23 Neurovascular Unit, University Health Network/Toronto Western Hospital, Toronto, Canada
| | - Alexandre Poppe
- 24 Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Gustavo Saposnik
- 3 Faculty of Medicine (Neurology), University of Toronto, Toronto, Canada.,25 Stroke Research Unit, St. Michael's Hospital, Toronto, Canada
| | - Mukul Sharma
- 26 Division of Neurology, Department of Medicine, McMaster University, Hamilton, Canada
| | - Sanjit Bhogal
- 5 workHORSE Consulting Group, London, Ontario, Canada
| | | | - M Patrice Lindsay
- 27 Heart and Stroke Foundation of Canada, Toronto, Canada.,28 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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16
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Stokes N, Kikucki J. Management of Cardiac Arrest in the Pregnant Patient. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:57. [DOI: 10.1007/s11936-018-0652-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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