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

Massive Pulmonary Embolism in a Pregnant Woman with an Excellent Response to Early Thrombolytic Therapy

Thrombolytic agents have been used successfully to treat patients with massive pulmonary embolism and cardiorespiratory insufficiency. Experience with these drugs in pregnancy is limited, nevertheless. We report a 32-year-old pregnant female, who was at 16 weeks of gestation, presented with acute collapse and progressive dyspnea caused by massive pulmonary embolism. The diagnosis was rapidly made in the emergency department with two dimensional-doppler echocardiography that showed signs of right ventricular dysfunction and pulmonary hypertension, as well as direct visualisation of large thrombus at the bifurcation of the main pulmonary artery. Because of significant haemodynamic instability and no improvement after intravenous heparin, the patient was successfully treated with recombinant tissue plasminogen activator and low-molecular-weight heparin. The response to fibrinolytic therapy was excellent without haemorrhagic complications and a healthy child was born at term. We conclude that early thrombolytic therapy may be a reasonable treatment for pregnant patients with unstable pulmonary embolism. (Hong Kong j.emerg.med. 2014;21:260-265)

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.

Echocardiography for patients undergoing extracorporeal cardiopulmonary resuscitation: a primer for intensive care physicians

Echocardiography is an invaluable tool in the management of patients with extracorporeal cardiopulmonary resuscitation (ECPR) and subsequent extracorporeal membrane oxygenation (ECMO) support and weaning. At the very beginning, echocardiography can identify the etiology of cardiac arrest, such as massive pulmonary embolism and cardiac tamponade. Eliminating these culprits saves life and may avoid the initiation of extracorporeal cardiopulmonary resuscitation. If the underlying causes are not identified or intrinsic to the heart (e.g., such as those caused by cardiomyopathy and myocarditis), conventional cardiopulmonary resuscitation (CCPR) will continue to maintain cardiac output. The quality of CCPR can be monitored, and if cardiac output cannot be maintained, early institution of extracorporeal cardiopulmonary resuscitation may be reasonable. Cannulation is sometimes challenging for extracorporeal cardiopulmonary resuscitation patients. Fortunately, with the help of ultrasonography procedures including localization of vessels, selecting a cannula of appropriate size and confirmation of catheter tip may become easy under sophisticated hand. Monitoring of cardiac function and complications during extracorporeal membrane oxygenation support can be done with echocardiography. However, the cardiac parameters should be interpreted with understanding of hemodynamic configuration of extracorporeal membrane oxygenation. Thrombus and blood stasis can be identified with ultrasound, which may prompt mechanical and pharmacological interventions. The final step is extracorporeal membrane oxygenation weaning. A number of studies investigated the accuracy of some echocardiographic parameters in predicting success rate and demonstrated promising results. Parameters and threshold for successful weaning include aortic VTI ≥ 10 cm, LVEF > 20-25%, and lateral mitral annulus peak systolic velocity >6 cm/s. However, the effectiveness of echocardiography in ECPR patients cannot be determined in observational studies and requires randomized controlled trials in the future. The contents in this review are well known to echocardiography specialists; thus, it should be used as an educational material for emergency or intensive care physicians. There is a trend that focused echocardiography is performed by intensivists and emergency physicians.

Venous Thromboembolism in Pregnancy

The risk of venous thromboembolism (VTE) is increased in pregnancy and puerperium. Thrombophilia has been identified in pregnancy-related VTE. Venous ultrasound and ventilation-perfusion lung scanning are the initial tests; pulmonary angiography should be performed if necessary for the definitive diagnosis. Anticoagulation is achieved with heparin antepartum and warfarin postpartum. Low molecular weight heparin has been effective and safe in pregnancy. Thrombolytic therapy has been administered to pregnant patients.

Review and Outcome of Prolonged Cardiopulmonary Resuscitation

The maximal duration of cardiopulmonary resuscitation (CPR) is unknown. We report a case of prolonged CPR. We have then reviewed all published cases with CPR duration equal to or more than 20 minutes. The objective was to determine the survival rate, the neurological outcome, and the characteristics of the survivors. Measurements and Main Results. The CPR data for 82 patients was reviewed. The median duration of CPR was 75 minutes. Patients mean age was 43 ± 21 years with no significant comorbidities. The main causes of the cardiac arrests were myocardial infarction (29%), hypothermia (21%), and pulmonary emboli (12%). 74% of the arrests were witnessed, with a mean latency to CPR of 2 ± 6 minutes and good quality chest compression provided in 96% of the cases. Adjunct therapy included extracorporeal membrane oxygenation (18%), thrombolysis (15.8%), and rewarming for hypothermia (19.5%). 83% were alive at 1 year, with full neurological recovery reported in 63 patients. Conclusion. Patients undergoing prolonged CPR can survive with good outcome. Young age, myocardial infarction, and potentially reversible causes of cardiac arrest such as hypothermia and pulmonary emboli predict a favorable result, especially when the arrest is witnessed and followed by prompt and good resuscitative efforts.

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.

Successful treatment of massive pulmonary embolism in the 38th week of pregnancy

In 1998, a 32-year-old woman in week 38 of pregnancy was referred to our hospital because of swelling of the lower extremities and dyspnea at rest. A massive pulmonary embolism and thrombi in the right and left atria were detected. After a successful cesarean section, emergent pulmonary embolectomy was performed with the use of cardiopulmonary bypass. Both the mother and the fetus recovered without severe complications. Postoperatively, activated protein S deficiency was detected.

Thrombolysis during cardiopulmonary resuscitation in fulminant pulmonary embolism: a review

OBJECTIVE

To review current knowledge on thrombolysis in patients with fulminant pulmonary embolism (FPE) who need cardiopulmonary resuscitation (CPR).

DATA SOURCES

The bibliography for the study was compiled through a search of different databases between 1966 and 2000. References cited in the articles selected were also reviewed.

STUDY SELECTION

The selection criteria included all reports published on thrombolysis, pulmonary embolism, and CPR, from case reports and case series to controlled studies.

DATA SYNTHESIS

Very few studies evaluated thrombolysis in cases of FPE that required CPR and most of these were clinical case reports and case series with a low level of scientific evidence. There has been no clinical trial to address this issue.

CONCLUSIONS

FPE can frequently produce cardiac arrest, which has an extremely high mortality despite application of the usual CPR measures. The administration of thrombolytic therapy during CPR could help to reduce the mortality, although it has classically been contraindicated. There are no published clinical trials or other high-grade studies that evaluated the efficacy and safety of this approach. From the few existing studies, it can be inferred that thrombolysis may be efficacious and safe for patients with FPE who need CPR. However, a clinical trial is required to provide evidence of value for sound clinical decision-making.