Maternal Deaths: Pulmonary Embolism (Pe)

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PULMONARY EMBOLISM (PE)

Pulmonary embolism is the leading cause of maternal deaths in


many centers especially in the developed
countries after the sharp decline of maternal mortality due to
hemorrhage, hypertension and sepsis. While
deep venous thrombosis in the leg or in the pelvis is most likely
the cause of pulmonary embolism, but
in about 80–90%, it occurs without any previous clinical
manifestations of deep vein thrombosis. The
predisposing factors are those already mentioned in venous
thrombosis. The clinical features depend
on the size of the embolus and on the preceding health status of
the patient. The classical symptoms of
massive pulmonary embolism are sudden collapse with acute
chest pain and air hunger. Death usually
occurs within short time from shock and vagal inhibition.
The important signs and symptoms of pulmonary embolism
are: tachypnea (>20 breaths/min), dyspnea,
pleuritic chest pain, cough, tachycardia (>100 bpm), hemoptysis
and rise in temperature more than 37°C.
DIAGNOSIS : X-ray of the chest shows diminished vascular
marking in areas of infarction, elevation of the dome
of the diaphragm and often pleural effusion. It is useful to rule
out pneumonia, pulmonary infiltrates and atelectasis.
ECG: Tachycardia, right axis shift, nonspecific ST change,
right bundle branch block.
Arterial blood gas: PO2 more than 85 mm Hg on room air is
reassuring but does not rule out PE. Oxygen
saturation less than 95% on room air needs further investigation.
D-Dimer: A negative D-Dimer value may rule out the
diagnosis of PE. It has a high negative predictive value
(Ch. 41).
Doppler ultrasound can identify a DVT. When the test is
positive for DVT, anticoagulation therapy should
be started.

Lung scans (Ventilation/Perfusion scan or V/Q scan): Perfusion


scan will detect areas of diminished blood flow
whereas a reduction in perfusion with maintenance of ventilation
indicates pulmonary embolism. V/Q scanning is
the method of choice for patients with suspected PE and with
normal chest radiograph. High probability V/Q scan
suggests PE. Magnetic Resonance Imaging (MRI) can be used
in pregnancy as the risk of ionizing radiation is absent.
Pulmonary angiography is accurate to the diagnosis but has
got high risks of complications. Mortality rate is
0.5% and overall complication rate is 3%.
Spiral Computed Tomographic Pulmonary Angiography
(CTPA): It requires an IV contrast and simultaneous
imaging. CTPA is found to be less precise in pregnant as
compared to a nonpregnant woman.
Magnetic resonance angiography (MRA) with IV gadolinium:
It has got sensitivity of 100% and specificity of
95% in the diagnosis of PE.
Management: Prophylaxis (as mentioned in page 509).
Active treatment includes: (1) Resuscitation—cardiac
massage, oxygen therapy, intravenous heparin bolus dose
of 5,000 IU and morphine 15 mg (IV) are started. Heparin
remains the mainstay of therapy for VTE. Therapeutic doses
of LMWH [enoxaparin 1 mg/kg subcutaneous (SC) twice daily]
may be used. Antifactor Xa levels of 0.6-1 U/mL are to
be maintained. Heparin therapy (IV) should be continued for 5–
10 days until patient improves clinically. Thereafter,
it is changed to SC injections. Anticoagulation may need to be
continued for 6 weeks to 6 months depending upon
the case. Heparin level is maintained at 0.2–0.4 U/mL or the
activated partial thromboplastin time (APTT) about
twice the normal (1.5–2.5 times). (2) IV fluid support is
continued and blood pressure is maintained, if needed by
dopamine or adrenalin. (3) Tachycardia is counteracted by
digitalis. (4) Recurrent attacks of pulmonary embolism
necessitate surgical treatment like embolectomy, placement of
inferior caval filter or ligation of inferior vena cava
and ovarian veins. Surgical treatment is done following
pulmonary angiography.
Indications of inferior vena cava filters are: (a) absolute
contraindication to medical anticoagulation, (b) failure
of anticoagulation, (c) heparin-induced thrombocytopenia, (d)
allergy to heparin.
Contraindications of heparin therapy are: Women with
active antenatal or postpartum bleeding, Risk
of major hemorrhage (placenta previa), Coagulopathy,
Thrombocytopenia.

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