Extensive Pulmonary Embolism in late pregnancy associated with Anticardiolipin Antibodies (original) (raw)
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Evaluation and Initial Management of Pulmonary Embolism during Pregnancy and the Puerperium
Emergency Medicine - Open Journal, 2015
There is an increased risk of venous thromboembolism during pregnancy. The increased risk begins in the first trimester and remains until six weeks postpartum. This paper provides an update on diagnosing and managing pulmonary embolism in pregnancy. Initial workup includes a clinical assessment, baseline blood test, electrocardiogram and a chest radiograph. D-dimer test is not recommended during pregnancy and puerperium. Doppler ultrasound of lower limb is recommended in the presence of a clinical suspicion of deep vein thrombosis. Definitive diagnosis of pulmonary embolism is established with radiological imaging. The preferred imaging modality is isotope perfusion scan with a normal chest radiograph and computed tomographic pulmonary angiography if chest radiograph is abnormal. Therapeutic low molecular weight heparin is the anticoagulant of choice during pregnancy. Warfarin is contraindicated during pregnancy but can be used postpartum. Duration of therapy is at least three months and should continue for six weeks postpartum. An algorithm for diagnosis and management is suggested.
Pulmonary embolism in pregnancy
The Lancet, 2010
Pulmonary embolism (PE) is the leading cause of maternal mortality in the developed world. Mortality from PE in pregnancy might be related to challenges in targeting the right population for prevention, ensuring that diagnosis is suspected and adequately investigated, and initiating timely and best possible treatment of this disease. Pregnancy is an example of Virchow's triad: hypercoagulability, venous stasis, and vascular damage; together these factors lead to an increased incidence of venous thromboembolism. This disorder is often suspected in pregnant women because some of the physiological changes of pregnancy mimic its signs and symptoms. Despite concerns for fetal teratogenicity and oncogenicity associated with diagnostic testing, and potential adverse eff ects of pharmacological treatment, an accurate diagnosis of PE and a timely therapeutic intervention are crucial. Appropriate prophylaxis should be weighed against the risk of complications and off ered according to risk stratifi cation.
Embolic Diseases - Evolving Diagnostic and Management Approaches [Working Title]
Pregnancy and peripartum increase the risk of venous thromboembolism (VTE) by many folds. Interestingly, the VTE is more common during the pregnancy, whereas the pulmonary embolism is more frequent in postpartum period. There are various risk factors for the VTE and pulmonary embolism in these patients. The important risks are improper thromboprophylaxis, obesity, and multigravida. The clinical parameters and the d-dimer are not used for diagnosis of thromboembolism during pregnancy and in the postpartum period. The compression ultrasonography (CUSG) is commonly used for VTE diagnosis; for the pulmonary embolism diagnosis, one has to consider the radiation hazard to the fetus as well as to the mothers. Ventilation/perfusion scan is the imaging of choice for patient who has respiratory signs with normal chest radiograph. If chest X-ray is abnormal with suspicion of peripartum pulmonary embolism (PPE), the choice should be computed tomographic angiography. Heparin and its derivatives remained the anticoagulation of choice for the treatment of VTE as well as the PPE, as it is a shorter acting, easy to reverse with protamine sulfate. Proper thromboprophylaxis is the key for prevention of VTE and peripartum pulmonary embolism.
2003
A 37-year-old female patient was admitted for elective caesarean section (CS). Her laboratory and biochemical investigations were normal. She underwent CS due to large size of the baby under spinal analgesia. On the first postoperative day, she developed acute shortness of breath, cyanosis, sweating and cardiac arrest. She was resuscitated successfully with oxygen via facemask, cardiac massage and i.v fluids. ECG showed supraventricular tachycardia and incomplete right bundle branch block. Echocardiography revealed a mildly dilated left and right ventricle with 50mmHg mean pulmonary artery pressure (PAP). Spiral CT scan confirmed the diagnosis of saddle pulmonary embolism (PE). Dublex ultrasound was negative for leg and pelvic deep venous thrombosis (DVT). She was admitted to surgical intensive care unit (SICU) and received adenosine and labetalol to control cardiac arrhythmia. Her blood pressure was consistently low where she received intermittent boluses of ephedrine and adrenalin...
Massive pulmonary embolism in a patient undergoing Cesarean delivery
Journal of Clinical Anesthesia, 2012
A case of a 40 year old, 86 kg, G7P1 woman with a history of hypercoagulability, at 39.1 weeks' gestation, who presented for elective Cesarean section during spinal anesthesia, is presented. During closure of the uterus, she became unresponsive and went into asystolic cardiac arrest. During resuscitation, clinical signs suggested pulmonary embolism, as confirmed by transesophageal echocardiogram. She was anticoagulated and taken to the Cardiac Catheterization Laboratory; there, clot lysis was performed, resulting in massive bleeding. Embolization of the uterine arteries was attempted and was only partially successful in reducing the bleeding. She then underwent Cesarean hysterectomy to control the bleeding. She had a full recovery and was discharged on the sixth postoperative day.
Venous thromboembolism during pregnancy, postpartum or during contraceptive use
Thrombosis and Haemostasis, 2009
Venous thromboembolism (VTE) is a leading cause of maternal death during pregnancy or postpartum, and in women using hormonal contraceptives. However, important issues concerning its natural history and therapy remain unsolved, and most of the protocols for treatment of VTE in this patient population are based on data extrapolated from other populations. RIETE is an ongoing registry of consecutive patients with objectively confirmed, symptomatic, acute VTE. We examined the clinical characteristics and three-month outcome of all enrolled women with pregnancy, postpartum or using hormonal contraceptives. As of December 2008, 173 pregnant women, 135 postpartum, and 798 contraceptive users were enrolled. Of these, 438 (40%) presented with pulmonary embolism (PE) and 668 with deep-vein thrombosis (DVT).
Pulmonary Embolism and Intracardiac Type A Thrombus with an Unexpected Outcome
Case Reports in Cardiology, 2017
Detection of right heart thrombi (RHT) in the context of pulmonary thromboembolism (PE) is uncommon (4–18%) and increases the risk of mortality beyond the presence of PE alone. Type A thrombi are serpiginous and highly mobile and are thought to be originated from large veins and captured in-transit within the right heart. Optimal management of RHT is still uncertain. A 79-year-old woman, with a history of recent total hysterectomy with adnexectomy and a Wells procedure, presented to the emergency department following an episode of syncope. Computed tomography revealed bilateral PE and the presence of a right atrial thrombus. Transthoracic echocardiography demonstrated a free-floating type A thrombus in the right atrium, protruding into the right ventricle, and signs of pulmonary hypertension and right ventricle dysfunction. Considering the recent surgery and clinical stability, treatment with heparin alone was decided. Subsequent clinical improvement was observed and echocardiograph...
Medicolegal aspects of Maternal Deaths due to Pulmonary Thromboembolism
Sri Lanka Journal of Forensic Medicine, Science & Law, 2015
A state of hypercoagulability protects pregnant women from bleeding tendency which leads to pulmonary thromboembolism and results in medicolegal issues. Case 01 32 year old pregnant female who developed weakness of legs, and was suspected to have Spinal Tuberculosis. Lower Segment Caesarian Section was performed and Heparin was started as she was immobile. Vertebral surgery was performed and anticoagulants were stopped. She died due to sudden onset difficulty of breathing. Allegations of medical negligence were raised by the relatives at the autopsy. The autopsy revealed bilateral Deep Vein Thrombosis (DVT) and pulmonary embolism. Case 02 A mother who presented with a first trimester abortion and pain in right leg died following sudden onset shortness of breath. She also had a history of a previous first trimester abortion. Autopsy revealed an embolus in the pulmonary artery with swollen and congested right leg without DVT. CONCLUSIONS Case 01 Regarding the allegations of medical negligence, the legal authorities will consider whether the discontinuation of prophylactic anticoagulants before the 2 nd surgery was a necessity and whether it was for the best interest of the patient. Case 02 Immunological syndromes and inherited thrombophilia could be consideredas underlying causes for multiple first trimester abortions and Deep Vein Thrombosis. The Importance of performing the risk assessment of DVT when indicated is highlighted.