Pulmonary embolism is a leading cause of maternal death in developed countries. While deep vein thrombosis is usually the cause, pulmonary embolism often occurs without symptoms of deep vein thrombosis. Common risk factors include preexisting health conditions, pregnancy, and genetic predispositions. Diagnosis involves tests like chest X-rays, electrocardiograms, blood tests, ultrasound, lung scans, CT scans, and angiography. Treatment consists of oxygen therapy, intravenous heparin, anticoagulants like low molecular weight heparin, fluid support, and in severe cases embolectomy or inferior vena cava filters. Anticoagulation therapy may continue for weeks to months depending on the severity of
Pulmonary embolism is a leading cause of maternal death in developed countries. While deep vein thrombosis is usually the cause, pulmonary embolism often occurs without symptoms of deep vein thrombosis. Common risk factors include preexisting health conditions, pregnancy, and genetic predispositions. Diagnosis involves tests like chest X-rays, electrocardiograms, blood tests, ultrasound, lung scans, CT scans, and angiography. Treatment consists of oxygen therapy, intravenous heparin, anticoagulants like low molecular weight heparin, fluid support, and in severe cases embolectomy or inferior vena cava filters. Anticoagulation therapy may continue for weeks to months depending on the severity of
Pulmonary embolism is a leading cause of maternal death in developed countries. While deep vein thrombosis is usually the cause, pulmonary embolism often occurs without symptoms of deep vein thrombosis. Common risk factors include preexisting health conditions, pregnancy, and genetic predispositions. Diagnosis involves tests like chest X-rays, electrocardiograms, blood tests, ultrasound, lung scans, CT scans, and angiography. Treatment consists of oxygen therapy, intravenous heparin, anticoagulants like low molecular weight heparin, fluid support, and in severe cases embolectomy or inferior vena cava filters. Anticoagulation therapy may continue for weeks to months depending on the severity of
Pulmonary embolism is a leading cause of maternal death in developed countries. While deep vein thrombosis is usually the cause, pulmonary embolism often occurs without symptoms of deep vein thrombosis. Common risk factors include preexisting health conditions, pregnancy, and genetic predispositions. Diagnosis involves tests like chest X-rays, electrocardiograms, blood tests, ultrasound, lung scans, CT scans, and angiography. Treatment consists of oxygen therapy, intravenous heparin, anticoagulants like low molecular weight heparin, fluid support, and in severe cases embolectomy or inferior vena cava filters. Anticoagulation therapy may continue for weeks to months depending on the severity of
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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.