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Postpartum Occurence of Devastating Pulmonary Artery Thrombus and Multidisciplinary Collaboration
Abstract Number: F-49
Abstract Type: Case Report/Case Series
Pulmonary embolism remains a leading cause of maternal morbidity and mortality.(1) As many as 30 % of women with pulmonary embolism have no associated clinical evidence of deep vein thrombosis.(2) Unfortunately, delay in diagnosis can result in fatality that could be prevented with early evaluation, anticoagulation, and early surgical intervention. We offer a case regarding the anesthetic management of a woman who 27 days postpartum from cesarean delivery, presented with poor pulmonary status and emergently required cardiopulmonary bypass and cardiotomy with thromboembolectomy of the right atrium and bilateral pulmonary arteries. A multidisciplinary approach, early imaging, and emergent surgery resulted in a favorable outcome.
While we know that pregnancy is associated with a 4-fold increased risk of venous thrombosis and that both physiologic and functional changes are associated with this risk (3), could it be that timing also increases this risk? Some studies would also suggest that women are at higher risk for embolus in the third trimester and the first three weeks postpartum (4).
Our patient SM is a 28-year-old morbidly obese African-American who underwent repeat cesarean delivery indicated by her previous three cesarean sections. The cesarean was performed with a combined spinal epidural technique without incident. After routine discharge, she was readmitted 26 days postoperatively with a wound infection and hematometra. She underwent a debridement and dilatation and curettage (D&C). On postoperative day one from the D&C, she presented with increasing oxygen demands and poor pulmonary function. The initial concern was for postpartum cardiomyopathy and we obtained a transthoracic echocardiogram (Echo). Echo results revealed clots in the right atrium and right ventricle causing severe tricuspid regurgitation and cardiac failure. The patient underwent an emergent right- sided cardiac thromboembolectomy. General endotracheal anesthesia was achieved without complication. After sternotomy and initiation of cardiopulmonary bypass, multiple impressive clots were removed from the inferior vena cava, bilateral pulmonary arteries, as well as the right atrium. Post-bypass the patient was weaned on moderate vasopressor support. On post operative day one, an IVC filter was placed for bilateral deep vein thrombosis. Her ICU course was complicated by vaginal bleeding requiring transfusions and poor ventilator weaning. Two weeks after cardiac surgery, the patient was discharged home with aspirin, warfarin, metoprolol and pain medications. Her follow-ups have been unremarkable.
1. Clark SL.Maternal death in the 21st century. Prevention and relationship to cesarean delivery. Am J Obs Gyn
2. Marik PE. Venous thromboembolic disease and pregnancy. NEJM
3. Kujovich JL. Hormones and pregnancy: thromboembolic risks for women. Br J Haem
4. AbdulSultan A.Risk of first venous thromboembolism in and around pregnancy: a population-based cohort study. Br J Haem