Life threatening pulmonary embolism requiring emergency embelectomy
Abstract Number: F1C-7
Abstract Type: Case Report/Case Series
Pulmonary embolism (PE) is a leading cause of maternal mortality. We present a case of massive PE in a 24-year-old woman at 37 weeks and 4 days gestation who was transferred from an outside hospital on a heparin infusion to our institution for peripartum care and management of a suspected PE.
On admission, she was tachycardic (>150 bpm) and short of breath, with SpO2 91% on nasal oxygen. While awaiting CT angiography to confirm suspected PE, the fetal heart rate tracing deteriorated, and did not resolve with intrauterine resuscitation. After review of the treatment options, she elected for an emergent cesarean delivery with the knowledge that she may die from heart failure or hemorrhage due to anticoagulation.
After induction of general anesthesia with etomidate and succinylcholine, she became extremely hypotensive (blood pressure 75/50 mmHg), with ETCO2 15 mmHg. A male infant was delivered (APGAR scores 7,8). Bleeding was moderate, and she received 1 unit of red blood cells. A norephinephrine infusion was commenced and a transesophageal echo (TEE) revealed a dilated right ventricle with severe right heart strain. Arterial blood gas revealed a pH 7.14, PaO2 63 mmHg and PaCo2 53 mmHg. Inhaled nitric oxide and an infusion of milrinone was started. Despite pharmacologic support she remained hemodynamically unstable.
Emergent CT angiography confirmed near total occlusion of pulmonary arteries bilaterally. During the subsequent catheter embolectomy, she suffered three episodes of PEA cardiac arrest with successful resuscitation. Suction embolectomy and chest compressions cleared enough thrombotic material to improve right heart function, hemodynamics and oxygenation. Bilateral pulmonary artery thrombolytic catheters were placed to infuse alteplase. Vasopressors and sedatives were weaned overnight in the intensive care unit. She was extubated the next day and the pulmonary artery catheters were subsequently removed. She was discharged from hospital on post-operative day five with no signs of neurological deficit.
This case highlights the use of fluoroscopic cardiac monitoring to guide resuscitation in extremis when other modalities of cardiac output monitoring are not possible. Due to the confines of the interventional radiology suite, the requirement to try and maintain a sterile surgical field and the location of the C-arm, access to the patient was limited, and conventional cardiac output monitoring was not practical. Instead real time fluoroscopic images of the heart proved instrumental in guiding management. Progressive dilation and hypokinesis of the right ventricle were visible, and three times worsened until the moment of cardiac arrest. The effect of therapeutic interventions, including chest compressions, fluid therapy, thrombectomy, and pharmacologic agents were evident, allowing timely recognition of return of spontaneous circulation, and precise titration of fluid and pharmacologic therapy.