Fatal pulmonary embolism following spinal anaesthesia for Caesarean section

Abstract

SummaryPulmonary embolism remains one of the commonest causes of maternal death. Regional blockade is reported to decrease the incidence of postoperative thrombo-embolic disease. We describe a case in which a fatal pulmonary embolism followed an emergency Caesarean section for which the patient was given a spinal anaesthetic. We believe it to be thejirst time this has been reported. Key wordsAnaesthesia; obstetric. Anaesthetic technique, regional; spinal. Complications; pulmonary embolism.The report on Confidential enquiries into maternal deaths in the United Kingdom 1985-87, shows that pulmonary embolism and hypertensive disorders of pregnancy remain the most common causes of maternal mortality [I]. Of the 13 postpartum deaths from pulmonary embolism, seven followed Caesarean section, suggesting that the risk after operative delivery is markedly increased compared with vaginal delivery. Case historyAn unmarried 29-year-old primiparous woman presented in spontaneous labour at 41 weeks' gestation. Her antenatal course had been uneventful and did not include any periods of immobilisation. She weighed 97.4 kg, smoked 10 cigarettes a day and had been normotensive throughout her pregnancy.Labour initially progressed well, during which she required for analgesia one intramuscular injection of pethidine 100 mg and Entonox. After 9 h her labour failed to progress because of cephalopelvic disproportion and an emergency Caesarean section became necessary. There was no fetal distress. The pre-operative haemoglobin level was 12 g.dl-' and baseline readings of heart rate 100 beats.min-', blood pressure 130/85 mmHg and an oxygen saturation of 96% when breathing air were obtained. After premedication with 30 ml of sodium citrate the patient's circulation was preloaded with 1500 ml compound sodium lactate solution. She was turned onto her right side and a 26 g spinal needle was inserted at the L2-3 interspace. Clear cerebrospinal fluid was obtained and 2.5 ml of hyperbaric 0.5% bupivacaine was injected into the subarachnoid space. A bolus dose of 9 mg of ephedrine was given intravenously as prophylaxis against hypotension.Twelve minutes later the patient was delivered of a live female infant weighing 4.08 kg, with Apgar scores of 9 at 1 min and 10 at 5 min. The operation was complete 53 min after the spinal injection. There were no episodes of hypotension and the blood loss was estimated to be 400 ml. The patient recovered well, did not develop a headache and was sitting out of bed 20 h after the operation. She required three intramuscular injections of papaveretum 20 mg for analgesia in the first 24 h and nothing after that. On the second postoperative day her temperature was 37.9" C, but this settled spontaneously. It was noted that her calves were not tender. All observations remained normal, but owing to social circumstances she was not discharged until the eighth postoperative day.

Fatal massive intra-operative pulmonary embolism while placing a patient in the surgical position

“…A massive pulmonary embolism (PE) is a major catastrophe during the intra‐operative period [1, 2]. In a rare case of massive PE, it has been attributed to the patient's position on the orthopaedic fracture table [3].…”