Pulmonary embolism in a parturient: A diagnostic and management dilemma

Case

A 34 year old patient at 33 weeks of gestational age presented to the hospital with spontaneous rupture of membranes and vaginal bleeding. She complained of having central chest pain and shortness of breath on admission. Clinically, she was tachycardic but hemodynamically stable (SPO2 96%). Her ECG was unremarkable with no ischaemic changes and negative Troponin levels. A drop in her Hb was noted from 97 to 83g/dl. On examination, she had a transverse lie and cord presentation.

Background: BMI 34, Systolic cardiac arrest in 2011 with PPM in situ, Type 2 Diabetes Mellitus (poorly controlled), Epilepsy (frequent seizures despite being on dual anti epileptics), 2 cerebrovascular accidents leading to old cerebral areas of infarcts, Asthma, Pre-eclampsia, Two Caesarean sections in the past.

Management

A diagnosis of pulmonary embolism was suspected. In order to consider therapeutic anti coagulation, she would warrant management of ongoing antepartum haemorrhage. A Multidisciplinary decision involving ITU, Medicine, Anaesthetics, Obstetrics, Cardiology and Neonatal team  was taken to proceed with emergency LSCS with post operative HDU management. Patient underwent LSCS under spinal anaesthesia. Intraoperatively, placental abruption was confirmed. She later underwent CTPA following LSCS and a diagnosis of sub-segmental PE in left lower lobe was confirmed for which she was treated with therapeutic anticoagulants for 6 weeks.

Discussion

Thrombosis and thromboembolism remains the leading cause of direct maternal death during or up to six weeks after the end of pregnancy according to MBRACE-UK report 2022. Pulmonary embolism in the presence of multiple long term conditions can be difficult to diagnose and manage during pregnancy. This requires good team work and early involvement of critical care. 

This woman’s care is an excellent example of multidisciplinary involvement with appropriate planning and management at a district general hospital.

References:

1. Knight M, Bunch K, Tuffnell D, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK.18 Dec 2020
2. Sheen JJ, Haramati LB, Natenzon A, Ma H, Tropper P, Bader AS, et al.. Performance of low-dose perfusion scintigraphy and CT pulmonary angiography for pulmonary embolism in pregnancy. Chest. (2018) 153:152–60. 10.1016/j.chest.2017.08.005