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Pulmonary Artery Thrombectomy in a Postpartum Patient
Abstract Number: SA-79
Abstract Type: Case Report/Case Series
Introduction: Venous thromboemboli (VTE) can be disastrous in pregnant and postpartum patients. Prophylaxis is crucial but does not guarantee against embolic events. We present a case where a postpartum patient developed near fatal pulmonary embolus despite appropriate prophylaxis as well as management of emergent pulmonary thrombectomy.
Case Presentation: 36 year old female presented 3 days after cesarean section with sudden onset chest pain and shortness of breath. History was significant for VTE 5 years prior which was attributed to immobilization and oral contraceptives. During pregnancy she was placed on prophylactic enoxaparin until one week prior to her scheduled delivery, when she was transitioned to subcutaneous unfractionated heparin (UFH). Upon arriving to the hospital on PPD #3 she was tachycardic and tachypneic with SpO2 87% on room air. CT showed saddle pulmonary emboli. She was transferred to a tertiary medical center for further care. Following transfer she was taken to the operating room for emergent pulmonary artery thrombectomy. Despite cautious induction using fentanyl, midazolam, and propofol, she suffered near circulatory collapse requiring boluses of phenylephrine, epinephrine, vasopressin, and an epinephrine infusion; this was later presumed to be due to right-to-left shunting through a previously unrecognized patent foramen ovale (PFO). Intraoperative transesophageal echocardiography demonstrated right ventricular pressure and volume overload, pulmonary artery thrombus, and a PFO. She was started on inhaled epoprostenol and placed on cardiopulmonary bypass for thrombectomy and PFO closure. Epinephrine and milrinone were required post-bypass and she was extubated within hours of surgery. Ultrasound demonstrated right lower extremity DVTs. Postoperatively she was continued on therapeutic UFH, vasoactive infusions weaned, inferior vena cava filter placed, and transitioned to warfarin. She was discharged home POD 7 and continues to do well.
Discussion: Anticoagulation following cesarean section increases the risk of postpartum hemorrhage. Current guidelines recommend waiting 12 hours for prophylactic and 24 hours for therapeutic enoxaparin or UFH after delivery (1). Although treated appropriately, this patient likely developed VTE during the time prophylactic anticoagulation was held. Expedient transfer to a tertiary center for definitive operative management proved to be life-saving.
1. J Thromb Thrombolysis 41(2016): 92–128