ABSTRACT
Embolic events including thromboembolism, air embolism, and amniotic fluid embolism can cause cardiovascular collapse during cesarean delivery. Differentiation between the three conditions is challenging because they share many of the initial clinical and echocardiographic findings, but an accurate, definitive diagnosis allows the administration of specific therapy that may help in saving the life of the mother and/or the fetus. We report a case of cardiovascular collapse during cesarean delivery under general anesthesia; massive pulmonary thromboembolism was suspected and unfractionated heparin was administered. Cardiac arrest followed and was managed with standard cardiopulmonary resuscitation, resulting in return of spontaneous circulation. Postoperatively, the patient remained hemodynamically unstable in spite of heparin, norepinephrine infusions and intravenous fluids. A transthoracic echocardiogram revealed right-sided pressure overload. Thrombolysis was initiated. Streptokinase (1,500,000IU over 2hours) was administered with no clinical response, followed by infusion (100,000IU/h) for 12hours. The patient's hemodynamics improved gradually and she was successfully weaned from norepinephrine and mechanical ventilation. Significant bleeding ensued, necessitating discontinuation of anticoagulation and transfusion of red blood cells. Eventually, the patient was discharged home, in good condition, and on oral warfarin therapy.
Subject(s)
Cesarean Section/adverse effects , Shock/diagnosis , Shock/etiology , Adult , Anesthesia, General , Cardiopulmonary Resuscitation , Electrocardiography , Embolism, Amniotic Fluid , Female , Humans , Intraoperative Complications/diagnosis , Intraoperative Complications/therapy , Pregnancy , Pulmonary Embolism/diagnosis , Pulmonary Embolism/therapy , Respiration, Artificial , Shock/therapy , Thrombolytic TherapyABSTRACT
Massive pulmonary embolism in pregnancy is a major cause of maternal mortality; the management is challenging, and often requires aggressive therapy. Thrombolysis has been used, often with favorable outcome, but has not been previously reported in a patient presenting with an intrauterine death. We present a 29-year-old nulliparous patient who had a massive pulmonary embolus associated with fetal death in the third trimester of pregnancy. Diagnosis of pulmonary embolus was aided by transthoracic echocardiography and the patient was successfully treated with streptokinase.
