Successful pulmonary embolectomy for massive pulmonary embolism during pregnancy: A case report
Abstract Number: T-57
Abstract Type: Case Report/Case Series
Pulmonary embolism (PE) is the leading cause of maternal mortality and is always a complication to keep in mind during pregnancy. Management of PE in pregnant women is not established. We herein report the case of woman who delivered under epidural analgesia after pulmonary embolectomy for severe pulmonary embolism that occurred during pregnancy.
A 35-year old G1P0 nulliparous woman sought medical advice at 28 weeks of gestation due to exertional dyspnea. CT scan showed bilateral pulmonary artery thrombi. A transthoracic echocardiography showed a right ventricular thrombus. We planned an emergent thrombectomy because of the mobility of the right ventricular thrombus and risk of exacerbation of PE.
We placed an intracardiac echography probe intravenously via the right femoral vein to monitor umbilical artery pulse wave via Doppler. After induction of anesthesia, the patient’s blood pressure could not be measured; hence, emergent cardio pulmonary bypass (CPB) was performed via median sternotomy followed by cardiac resuscitation. Approximately 10 minutes after the hemodynamic collapse, the intravenous umbilical artery monitor detected a decrease in fetal heart rate to about 80 bpm. Immediately after establishing the extracorporeal circulation, fetal heart rate recovered rapidly and remained stable during the procedure while keeping the CPB average perfusion pressure above 70 mmHg. Thrombectomy were successfully performed under cardiac arrest (Figure). At 32 weeks of gestation, she was discharged.
She was readmitted to hospital for labor at 38 weeks of gestation. Then, epidural anesthesia was administered to protect the thoracic wound site and to reduce cardiac load. Ropivacaine 0.1% with 2mcg/ml fentanyl were continuously administered through the epidural catheter by patient control epidural analgesia. During labor, epidural analgesia was adequate and no hemodynamic changes occurred. A healthy male infant was delivered by vacuum extraction. Both the child and his mother were discharged without complications.
Intra cardiac echography is useful for fetal heart rate monitoring during emergent cardiac surgery during pregnancy. Careful CPB management is also important to maintain uteroplacental blood flow in these patients. Although there is no fixed delivery method of pregnant women after thoracotomy, epidural analgesia during labor was useful for reducing heart load and wound traction.