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

Abstract

Background/Aim: Acute pulmonary embolism during cesarean section is extremely rare and only a limited number of cases have been reported in literature. The aim of this study was to report a case of acute high risk pulmonary embolism during elective cesarean section treated with systemic thrombolysis and discuss the multidisciplinary management in both early recognition and prompt treatment. Case Report: A 39-year-old, G5P2, ASA II parturient presented for repeat cesarean section under general anesthesia. A sudden drop in end-tidal CO 2 after placenta delivery combined with significant hemodynamic instability after an uneventful intraoperative course was strongly indicative of pulmonary embolism. Urgent transthoracic ultrasound revealed a sizable thrombus in the inferior vena cava and the right atrium. Thrombolysis was carried out intraoperatively using recombinant tissue plasminogen activator, which was administered under continuous US monitoring until thrombus resolution. This resulted in significant bleeding that was treated in a stepwise manner beginning with implementation of massive transfusion protocol, Bakri balloon placement, and rescue hysterectomy several hours after the event. Follow-up was uneventful and she was discharged on the 12 th postoperative day. Conclusion: Though pregnancy is one of the major risk factors of the development of venous thromboembolism, acute intraoperative pulmonary embolism is extremely rare. Specific guidelines for the management of such cases are difficult to issue due to the paucity of relevant data. Thus, an individualized approach by a multidisciplinary team for diagnosis and intervention is mandated.Hemostatic alterations in normal pregnancy, characterized by marked increase in the procoagulant activity (FVII, FVIII, fibrinogen, FX, vWF), together with venous outflow obstruction due to uterus enlargement, predispose to a hypercoagulable state (1). These changes are maximal around term. The co-existence of other risk factors, such as prolonged immobilization, obesity, and cesarean section (CS) increase the risk for venous thromboembolism (VTE) in the obstetric population (2). Moreover, known inherited coagulation disorders complicate further the matter and require a multidisciplinary approach.Since pregnancy represents a hypercoagulable state, it is not surprising that VTE remains one of the leading causes of 498

Successfully conservative management of the uterus in acute pulmonary embolism during cesarean section for placenta previa: a case report from Tu Du Hospital, Vietnam and literature review

“…The modern management of PE includes anti-coagulation, thrombolysis, and surgical pulmonary embolectomy. The choice of management should be based on the patient’s status and the size of the thrombus clot [ 26 , 38 ]. However, no practical guidelines have been established for this difficult entity [ 46 ].…”

“…However, the risks and benefits of this drug administration are still controversial due to the risk of thrombosis [ 55 – 57 ]. Karakosta et al have recently reported a case of uterine conservation after acute life-threatening PE during C-Section which required postpartum rescue hysterectomy due to massive bleeding [ 26 ]. Initial uterine conservation carries the risk of subsequent emergency hysterectomy.…”

“…Early surgical embolectomy and bridged with extracorporeal membrane oxygenation may be required in some severe cases [ 23 – 25 ]. Cesarean hysterectomy is often undertaken due to the massive active bleeding after failed conservative treatment, coagulation disturbances, and a high risk of postpartum hemorrhage (PPH) that treatment of PE requires [ 26 ]. Nevertheless, hysterectomy is not optimal for a young woman who desires to preserve fertility.…”