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The Wrong Kind of Saddle Block
Abstract Number: RF6BI-453
Abstract Type: Case Report Case Series
We present a complex obstetric medically challenging case of a 27 year old G1P0 Caucasian female at 33 weeks and 3 days, who presented with an unprovoked massive saddle pulmonary embolism leading to intrauterine fetal demise, complicated by disseminated intravascular coagulopathy requiring emergent thrombolysis. The patient’s case was further exacerbated by respiratory failure and cardiac arrest necessitating a perimortem caesarean section and ultimately VA ECMO.
She presented to an outside hospital with chest pain, shortness of breath, and abdominal cramps that began several hours prior. The patient had a history of asthma, depression, and drug abuse, without a personal or family history of coagulopathy. She was found to have a “large pulmonary embolism noted in both main pulmonary arteries extending into the bilateral lobar, segmental, and subsegmental branches, particularly involving the right lower, middle, lingula, and left lower lobes with severe right heart strain.” Reassuring fetal heart tones were noted prior to transfer to our facility for a higher level of care. Upon arrival, she became hemodynamically unstable, cyanotic, tachycardic, and tachypneic requiring fluid resuscitation and pressor support. No fetal heart tones were noted at that time. She was emergently taken to interventional radiology for chemical thrombolysis and mechanical thrombectomy. The decision was made to delay intubation initially due to concern for progressive right heart failure and cardiovascular collapse, but was later intubated. Soon after partial retrieval of the emboli, the patient went into PEA. ACLS was initiated requiring fifteen rounds of chest compressions. A perimortem caesarean section was performed sixteen minutes after ACLS initiation. One minute after incision, baby was delivered and fascia was closed within two minutes. Almost immediately following the perimortem caesarean section, ROSC was achieved. The patient's course was further complicated by DIC with the timing and relation to the events unknown. Subsequently, the patient was started on VA ECMO and transported to SICU in a critical state. The patient was decannulated from VA ECMO on day 6 after the initial insult, extubated on day 10, and discharged from the hospital on day 17, without any neurological deficits. An extensive hematologic and obstetric workup followed.