Cesarean section complicated with presumed massive pulmonary embolism and cardiac arrest treated with rescue thrombolytic therapy—two case reports

Abstract

Background: Massive pulmonary embolus (PE), resulting in cardiac arrest during pregnancy and postpartum, is a rare but potentially catastrophic event. The most severe manifestation of massive PE is cardiovascular instability, including cardiogenic shock and cardiac arrest requiring intensive care unit (ICU) admissions. Up to 23% of high-risk PE pregnant and postpartum patients experience cardiac arrest.Case Description: Case 1, a 34-year-old obese patient, with a twin pregnancy, had cesarean sections in the 24th week of pregnancy due to premature abruption of the placenta. Immediately after the birth, she experienced a sudden cardiac arrest. Treatment was initiated in line with ALS, heparine and alteplase was administered due to suspected massive pulmonary embolism. After 20 minutes from ROSC, the uterine atony and severe hemorrhage occurred, and a postpartum hysterectomy was performed. The mother and two daughters are alive in 2021. Case 2, a 24-year-old obese patient had a cesarean section due to abruption of the placenta in the 28th week of pregnancy. Twelve hours after cesarean delivery, the patient's condition suddenly deteriorated. The patient reported dyspnea, chest pain, and presented cyanosis. The blood pressure was 66/30 mmHg, heart rate 130/min, tachypnea with a respiratory rate of 30/min, saturation 80% on air.High flow oxygen via face mask with reservoir (FiO 2 0.85) and ephedrine 2×10 mg i.v. were administered.Due to suspected pulmonary embolism, a bolus of 5,000 IU of heparin was administered iv. Despite the implemented measures, cardiac arrest was confirmed with the initial rhythm of PEA (sinus tachycardia 120/min). Treatment consistent with ALS was initiated. Due to the high probability of pulmonary embolism, a bolus of alteplase was administrated. ROSC was obtained 7 minutes later. Because of obstetric hemorrhage hysterectomy was performed. The mother and the baby are alive in 2022. Conclusions:In light of current evidence, presented data suggest that early and aggressive recombinant thrombolytic use in case of cardiac arrest and suspected PE in obstetric patients may be life-saving, effective treatment with a good neurological outcome. Major bleeding complications should be anticipated when administering this therapy.

Heparin anticoagulant reduces mortality in patients with cardiac arrest: A retrospective cohort study from the eICU database

“…Numerous studies have consistently reported favourable thrombolysis outcomes when managing patients with CA, particularly CAs possibly caused by a pulmonary embolism [16,24,25]. However, bleeding complications associated with this treatment modality are relatively high [17,24]. Consequently, thrombolysis cannot be a routine CA intervention in clinical practice.…”

Subsegmental Pulmonary Embolism Post Cesarean Section: A Case Report

“…This can3 be achieved by using either mechanical or pharmacological methods. Starting patients on anticoagulation early in case of suspected PE may be lifesaving and crucial to prevent catastrophic sequalae [6]. The diagnosis of suspected PE includes compression lower limbs ultrasound in case of signs and symptoms of deep vein thrombosis (DVT).…”

Systemic Thrombolysis for Treatment of Acute Life-threatening Pulmonary Embolism During Cesarean Section Followed by Post-partum Rescue Hysterectomy: A Case Report and Review of the Literature

“…This case involves a 34-year-old obese parturient with twin pregnancy undergoing CD due to premature abruption of the placenta. She experienced sudden cardiac arrest immediately after birth and although she was successfully treated with heparin and rt-PA, she underwent rescue hysterectomy soon after ROSC (18). In general, VTE associated mortality rates in the peripartum period are low, though higher that the non-obstetric population (8).…”