"Multidisciplinary Team Management of a Pregnant Woman With Newly Diagnosed Multiple Pulmonary Embolisms and Foetal Compromise, When to Deliver?"

Abstract

Background: Thromboembolic disease, including pulmonary embolism (PE) is the leading cause of direct maternal mortality in the UK (UKOSS, [1]). In women with diabetes, there is usually an increase in resistance to insulin within the placenta and taking corticosteroids often causes an increase in insulin requirements. A sudden reduction at term is an indication of a failing placenta and increases the risk of sudden stillbirth, requiring an expedited delivery.Case: Our case report concerns a pregnant woman, with insulin-controlled type 2 diabetes mellitus (DM), who developed multiple PEs and was treated with low molecular weight heparin (LMWH) but quickly developed signs of impending foetal distress. A multidisciplinary team (MDT) planned to expedite delivery due to a risk of sudden stillbirth in this high-risk woman with possible placental insufficiency. As the PEs were recently diagnosed (Clexane had only been administered for seven days), risks of clot embolisation and maternal death would increase if the Clexane was stopped to allow induction of labour and vaginal delivery; there was also the risk of excessive bleeding if the last dose was 12 hours before the Caesarean section. The treatment dose of Clexane was therefore changed from twice to once daily and delivery was performed by Caesarean section. This made it easier to time and minimise the duration of delivery to minimise time off anticoagulation medication.Results: A baby girl was born in good condition, weighing 3,070 g. The mother remained in a stable condition. Prophylactic Clexane 40 mg was given subcutaneously six hours after surgery with full treatment dose 150 mg subcutaneously once daily for 24 hours after delivery. Conclusion:This case was complicated by a new diagnosis of multiple PEs and risks of maternal morbidity and mortality that had to be balanced with risks to the foetus. An MDT approach to management of multiple comorbidities resulted in a safe outcome for both mother and child.