Peripartum pulmonary embolism: Anesthetic and surgical considerations
Affiliation(s)
Department of Anesthesia, Hamad Medical Corporation, Weil Cornell Medical College, Doha, Qatar. Department of OBGY, Hamad Medical Corporation, Doha, Qatar.
Department of Anesthesia, Hamad Medical Corporation, Weil Cornell Medical College, Doha, Qatar. Department of OBGY, Hamad Medical Corporation, Doha, Qatar.
ABSTRACT
Pregnancy and peripartum period leads to Virchow’s triad (hypercoagulability, venous stasis and vascular injury) thereby increasing the risk of thromboembolism by many folds in these patients. Accurate diagnosis of peripartum pulmonary embolism is pertinent for reducing morbidity and mortality. Accurate diagnosis is also vital for avoiding the adverse effects of unwanted anticoagulation in pregnant mother and fetus in a patient wrongly diagnosed with this condition. Computerized tomographic pulmonary angiography has a high specificity and sensitivity in comparison to ventilation/perfusion scan for diagnosis of peripartum pulmonary embolism (PPE). It has a lower fetal radiation exposure and aids in arriving at an alternative diagnosis, if PPE is absent. Low molecular weight heparin is the medication of choice in the treatment of peripartum pulmonary embolism. Thrombolysis is considered in patients with massive PPE and hemodynamic instability, refractory hypoxia or right ventricular dysfunction. Regional anesthesia/analgesia can be given safely in these patients. We report two cases of PPE and review the anesthetic and surgical consideration.
Cite this paper
Shaikh, N. , Ummunnisa, F. , Aboobacker, N. , Gazali, M. and Kokash, O. (2013) Peripartum pulmonary embolism: Anesthetic and surgical considerations. Open Journal of Obstetrics and Gynecology, 3, 158-164. doi: 10.4236/ojog.2013.31A030.
Shaikh, N. , Ummunnisa, F. , Aboobacker, N. , Gazali, M. and Kokash, O. (2013) Peripartum pulmonary embolism: Anesthetic and surgical considerations. Open Journal of Obstetrics and Gynecology, 3, 158-164. doi: 10.4236/ojog.2013.31A030.
References
[1] Bourjeily, G., Paidas, M., khalil, H., Rosene-Montella, K. and Rodger, M. (2010) Pulmonary embolism in pregnancy. Lancet, 375, 500-512. doi:10.1016/S0140-6736(09)60996-X [2] Mathew, S. (2006) Imaging pulmonary embolism in pregnancy: What is the most appropriate imaging protocol? British Journal of Radiology, 79, 441-444. doi:10.1259/bjr/15144573 [3] James, A.H., Jamison, M.G., Brancazio, L.R., et al. (2006) Venous thromboembolism during pregnancy and the post-partum period. Incidence, risk factors and mortality. American Journal of Obstetrics & Gynecology, 194, 1311-1315. doi:10.1016/j.ajog.2005.11.008 [4] Kobayashi, T., Nakabayashi, M., Ishikawa, M., Adachi, T., kobashi, G., Maeda, M. and Ikenoue, T. (2008) Pulmonary thromboembolism in obstetrics and gynecology increased by 6.5 folds over past decade in Japan. Circulation Journal, 72, 753-756. doi:10.1253/circj.72.753 [5] Khosla, R. (2006) Diagnosis of pulmonary embolism. Indian Journal of Critical Care Medicine, 10, 105-111. [6] Al-Gahtani, F.H. (2009) Pregnancy associated venous thromboembolism. Part 1—Deep venous thrombosis. Saudi Medical Journal, 1, 13-23. [7] Heit, J.A., Kobberuig, C.E., James, A.H., et al. (2005) Trends in the incidence of venous thromboembolism during pregnancy or post-partum: 30 years of population based study. Annals of Internal Medicine, 143, 697-706. [8] Macklon, N.S. and Greer, I.A. (1996) Venous thromboembolic disease in obstetric and gynecology: The Scottish experiences. Scottish Medical Journal, 41, 83-86. [9] James, A.H., Jamison, M.G., Brancazio, L.R., et al. (2006) Venous thromboembolism during pregnancy and postpartum period: Incidence, risk factors and mortality. American Journal of Obstetrics & Gynecology, 194, 1311-1315. doi:10.1016/j.ajog.2005.11.008 [10] Robertson, L., Wu, O., Langhorne, P., et al. (2006) Thrombophilia in pregnancy: A systematic review. British Journal of Haematology, 132, 171-196. doi:10.1111/j.1365-2141.2005.05847.x [11] Rosenkranz, A., Hiden, M., Leschnik, B., Weiss, E.C., Schlembach, D., Lang, U., et al. (2008) Calibrated automatic thrombin generation in normal uncomplicated pregnancy. Thrombosis and Haemostasis, 99, 331-337. [12] Leung, A.N., Bull, T.M., Jaeschke, R., Lochhood, C.J., Boiselle, P.M., Hurwitz, L.M., et al. (2011) An official American thoracic society/society of thoracic radiology clinical practice guigline: Evaluation of suspected pulmonary embolism in pregnancy. American Journal of Respiratory and Critical Care Medicine, 184, 1200-1208. doi:10.1164/rccm.201108-1575ST [13] Morse, M. (2004) Establishing a normal range for D-Dimer levels through pregnancy to aid in diagnosis of pulmonary embolism and deep venous thrombosis. Journal of Thrombosis and Haemostasis, 2, 1202-1204. doi:10.1111/j.1538-7836.2004.00776.x [14] de Swlet, M. (1999) Management of pulmonary embolus in pregnancy. European Heart Journal, 20, 1378-1385. doi:10.1053/euhj.1999.1584 [15] Ginsberg, J.S., Hirsh, J., Rainbow, A.J. and Coates, G. (1989) Risk to the fetus of radiological procedures used in the diagnosis of maternal venous thromboembolism disease. Journal of Thrombosis and Haemostasis, 61, 189-196. [16] Blachere, H., Latrabe, V., Montaudon, M., Valli, N., Couffinhal, T., Raherisson, et al. (2000) Pulmonary embolism revealed on helical CT angiography: Comparison with ventilation/perfusion radionuclide lung scanning. American Journal of Roentgenology, 174, 1041-1047. [17] Winer-Muram, H.T., Boone, J.M., Brown, H.L., Jennings, S.G., Mabie, W.C. and Lombard, G.T. (2000) Pulmonary embolism in pregnant patients; fetal radiation dose with helical CT. Radiology, 224, 487-492. doi:10.1148/radiol.2242011581 [18] Powell, T. and Muller, N.L. (2003) Imaging of acute pulmonary thromboembolism: should spiral computed tomography replace the ventilation perfusion scan? Clinics in Chest Medicine, 24, 29-38. doi:10.1016/S0272-5231(02)00074-6 [19] Hall, J.G., Pauli, R.M. and Wilson, K.M. (1980) Maternal and fetal sequelae of anticoagulation during pregnancy. American Journal of Medicine, 68, 122-140. doi:10.1016/0002-9343(80)90181-3 [20] Kearon, C. and Hiresh, J. (1997) Management of anticoagulation before and after surgery. The New England Journal of Medicine, 336, 1566-1511. doi:10.1056/NEJM199705223362107 [21] Bates, S.M., Greer, I.A., Pabinger, I., Sofaer, S., Hirsh, J. (2008) Embolism, thrombophilia, antithrombotic therapy and pregnancy. American College of chest physician evidence based clinical guidelines. Chest, 56, 844-886. doi:10.1378/chest.08-0761 [22] Moen, V., Dahlgren, N. and Irestedt, L. (2004) Severe neurological complications after central neuroaxial blockades in Sweden 1990-1999. Anesthesiology, 101, 950-959. doi:10.1097/00000542-200410000-00021 [23] Kitao, T., Veno, Y., Sekikawa, A., Tatsumi, Y., Nakashima, M., Kan, K., et al. (2008) Anesthetic management in a patient with pulmonary embolism. Masuli, 57, 761-763. [24] Horlocker, T.T., Wedel, D.J., Rowlingson, J.C., et al. (2010) Regional anesthesia in patients receiving antithrombotic or thrombolytic therapy. American society of regional anesthesia and pain management, evidence based guidelines. Regional Anesthesia and Pain Medicine, 35, 64. doi:10.1097/AAP.0b013e3181c15c70 [25] Horlocker, T.T., Wedel, D.J., Roswlingson, J.C., Enneking, K., Kopp, S.L., Benzon, H.T., et al. (2012) Regional anesthesia in patient receiving antithrombotic or thrombolytic therapy. Regional Anesthesia and Pain Medicine, 35, 64-74. doi:10.1097/AAP.0b013e3181c15c70
[1] Bourjeily, G., Paidas, M., khalil, H., Rosene-Montella, K. and Rodger, M. (2010) Pulmonary embolism in pregnancy. Lancet, 375, 500-512. doi:10.1016/S0140-6736(09)60996-X [2] Mathew, S. (2006) Imaging pulmonary embolism in pregnancy: What is the most appropriate imaging protocol? British Journal of Radiology, 79, 441-444. doi:10.1259/bjr/15144573 [3] James, A.H., Jamison, M.G., Brancazio, L.R., et al. (2006) Venous thromboembolism during pregnancy and the post-partum period. Incidence, risk factors and mortality. American Journal of Obstetrics & Gynecology, 194, 1311-1315. doi:10.1016/j.ajog.2005.11.008 [4] Kobayashi, T., Nakabayashi, M., Ishikawa, M., Adachi, T., kobashi, G., Maeda, M. and Ikenoue, T. (2008) Pulmonary thromboembolism in obstetrics and gynecology increased by 6.5 folds over past decade in Japan. Circulation Journal, 72, 753-756. doi:10.1253/circj.72.753 [5] Khosla, R. (2006) Diagnosis of pulmonary embolism. Indian Journal of Critical Care Medicine, 10, 105-111. [6] Al-Gahtani, F.H. (2009) Pregnancy associated venous thromboembolism. Part 1—Deep venous thrombosis. Saudi Medical Journal, 1, 13-23. [7] Heit, J.A., Kobberuig, C.E., James, A.H., et al. (2005) Trends in the incidence of venous thromboembolism during pregnancy or post-partum: 30 years of population based study. Annals of Internal Medicine, 143, 697-706. [8] Macklon, N.S. and Greer, I.A. (1996) Venous thromboembolic disease in obstetric and gynecology: The Scottish experiences. Scottish Medical Journal, 41, 83-86. [9] James, A.H., Jamison, M.G., Brancazio, L.R., et al. (2006) Venous thromboembolism during pregnancy and postpartum period: Incidence, risk factors and mortality. American Journal of Obstetrics & Gynecology, 194, 1311-1315. doi:10.1016/j.ajog.2005.11.008 [10] Robertson, L., Wu, O., Langhorne, P., et al. (2006) Thrombophilia in pregnancy: A systematic review. British Journal of Haematology, 132, 171-196. doi:10.1111/j.1365-2141.2005.05847.x [11] Rosenkranz, A., Hiden, M., Leschnik, B., Weiss, E.C., Schlembach, D., Lang, U., et al. (2008) Calibrated automatic thrombin generation in normal uncomplicated pregnancy. Thrombosis and Haemostasis, 99, 331-337. [12] Leung, A.N., Bull, T.M., Jaeschke, R., Lochhood, C.J., Boiselle, P.M., Hurwitz, L.M., et al. (2011) An official American thoracic society/society of thoracic radiology clinical practice guigline: Evaluation of suspected pulmonary embolism in pregnancy. American Journal of Respiratory and Critical Care Medicine, 184, 1200-1208. doi:10.1164/rccm.201108-1575ST [13] Morse, M. (2004) Establishing a normal range for D-Dimer levels through pregnancy to aid in diagnosis of pulmonary embolism and deep venous thrombosis. Journal of Thrombosis and Haemostasis, 2, 1202-1204. doi:10.1111/j.1538-7836.2004.00776.x [14] de Swlet, M. (1999) Management of pulmonary embolus in pregnancy. European Heart Journal, 20, 1378-1385. doi:10.1053/euhj.1999.1584 [15] Ginsberg, J.S., Hirsh, J., Rainbow, A.J. and Coates, G. (1989) Risk to the fetus of radiological procedures used in the diagnosis of maternal venous thromboembolism disease. Journal of Thrombosis and Haemostasis, 61, 189-196. [16] Blachere, H., Latrabe, V., Montaudon, M., Valli, N., Couffinhal, T., Raherisson, et al. (2000) Pulmonary embolism revealed on helical CT angiography: Comparison with ventilation/perfusion radionuclide lung scanning. American Journal of Roentgenology, 174, 1041-1047. [17] Winer-Muram, H.T., Boone, J.M., Brown, H.L., Jennings, S.G., Mabie, W.C. and Lombard, G.T. (2000) Pulmonary embolism in pregnant patients; fetal radiation dose with helical CT. Radiology, 224, 487-492. doi:10.1148/radiol.2242011581 [18] Powell, T. and Muller, N.L. (2003) Imaging of acute pulmonary thromboembolism: should spiral computed tomography replace the ventilation perfusion scan? Clinics in Chest Medicine, 24, 29-38. doi:10.1016/S0272-5231(02)00074-6 [19] Hall, J.G., Pauli, R.M. and Wilson, K.M. (1980) Maternal and fetal sequelae of anticoagulation during pregnancy. American Journal of Medicine, 68, 122-140. doi:10.1016/0002-9343(80)90181-3 [20] Kearon, C. and Hiresh, J. (1997) Management of anticoagulation before and after surgery. The New England Journal of Medicine, 336, 1566-1511. doi:10.1056/NEJM199705223362107 [21] Bates, S.M., Greer, I.A., Pabinger, I., Sofaer, S., Hirsh, J. (2008) Embolism, thrombophilia, antithrombotic therapy and pregnancy. American College of chest physician evidence based clinical guidelines. Chest, 56, 844-886. doi:10.1378/chest.08-0761 [22] Moen, V., Dahlgren, N. and Irestedt, L. (2004) Severe neurological complications after central neuroaxial blockades in Sweden 1990-1999. Anesthesiology, 101, 950-959. doi:10.1097/00000542-200410000-00021 [23] Kitao, T., Veno, Y., Sekikawa, A., Tatsumi, Y., Nakashima, M., Kan, K., et al. (2008) Anesthetic management in a patient with pulmonary embolism. Masuli, 57, 761-763. [24] Horlocker, T.T., Wedel, D.J., Rowlingson, J.C., et al. (2010) Regional anesthesia in patients receiving antithrombotic or thrombolytic therapy. American society of regional anesthesia and pain management, evidence based guidelines. Regional Anesthesia and Pain Medicine, 35, 64. doi:10.1097/AAP.0b013e3181c15c70 [25] Horlocker, T.T., Wedel, D.J., Roswlingson, J.C., Enneking, K., Kopp, S.L., Benzon, H.T., et al. (2012) Regional anesthesia in patient receiving antithrombotic or thrombolytic therapy. Regional Anesthesia and Pain Medicine, 35, 64-74. doi:10.1097/AAP.0b013e3181c15c70