|Year : 2012 | Volume
| Issue : 1 | Page : 38-39
Successful thrombolysis of right heart emboli-in-transit causing cardiac arrest during caesarean section
Supriya Bulchandani, Rabia Imtiaz
Department of Obstetrics and Gynaecology, Worcestershire Royal Hospital, United Kingdom
|Date of Web Publication||4-Aug-2012|
7 Coleford Close, Webheath, Redditch, B97 5UX Worcestershire
Source of Support: None, Conflict of Interest: None
We report a rare case of successful thrombolysis of right heart emboli-in-transit causing cardiac arrest, during caesarean section in a 42-year-old primigravida. This was diagnosed by intra-operative echocardiography. Return to spontaneous circulation was achieved. This was followed by massive post-partum haemorrhage managed conservatively. The lady was discharged home with a Greenfield Inferior Vena Caval filter and Warfarin. Systemic thrombolytic therapy is a challenging decision to make but is usually recommended if it is not contraindicated and the thrombi are demonstrated in more than one cardiac chamber, entailing a higher risk of surgical intervention. However, the potential for massive obstetric bleeding and further side effects must be considered and adequate strategies and resources should be available.
Keywords: Caesarean section, cardiac arrest, cardiac thrombi
|How to cite this article:|
Bulchandani S, Imtiaz R. Successful thrombolysis of right heart emboli-in-transit causing cardiac arrest during caesarean section. J Obstet Anaesth Crit Care 2012;2:38-9
|How to cite this URL:|
Bulchandani S, Imtiaz R. Successful thrombolysis of right heart emboli-in-transit causing cardiac arrest during caesarean section. J Obstet Anaesth Crit Care [serial online] 2012 [cited 2019 Jun 26];2:38-9. Available from: http://www.joacc.com/text.asp?2012/2/1/38/99319
| Introduction|| |
Cardiopulmonary arrest occurs in 1:30 000 pregnancies. We report a rare case of successful thrombolysis of right heart emboli-in-transit causing cardiac arrest during caesarean section. We found only two reported cases in the literature of cardiac arrest during caesarean section. Currently, no consensus exists for the appropriate treatment of echocardiographically diagnosed mobile right heart masses. This may lead to unnecessary delay in the implementation of the most appropriate treatment for these patients. 
| Case Report|| |
A 42-year-old primigravida with major placenta praevia, presented to hospital at 33 weeks and 5 days with a history of vaginal bleeding. The baby was in transverse lie. A caesarean section was planned in view of ongoing vaginal bleeding. Four units of blood were cross-matched and available in theatre.
A minute after delivery of a liveborn baby boy under spinal anesthetic, she suffered a cardiac arrest diagnosed as pulseless electrical activity and cardiopulmonary resuscitation (CPR) was commenced. The cardiac arrest team was in attendance as per hospital policy within 5 min of the arrest. A trans-thoracic echocardiogram in theatre revealed an embolus in the right atrium and ventricle. A diagnosis of pulmonary embolism "in transit" was made. This was treated with thrombolysis using Alteplase intravenously. Return of spontaneous circulation was seen at 10 min after CPR. Supportive treatment with intravenous fluids, dobutamine, adrenaline infusion, and tranexamic acid intravenously was commenced. A syntocinon infusion was commenced and a Bakri Balloon was inserted in the uterus along with a vaginal pack. Misoprostol 800 mcg was administered per rectum. She lost 1800 ml of blood at caesarean section. Following this, she was transferred to the Intensive Care Unit (ITU) and Alteplase was continued intravenously with a view to maintain activated partial thromboplastin time (APTT) in the range of 1.5 to 2.5. She was monitored with a central venous line, a brachial arterial line, and a pulmonary artery catheter. A plan was made to commence heparin if APTT dropped below 1.5. A subsequent echocardiogram in ITU revealed no evidence of a thrombus. She received 20 units of red cells, 8 units of fresh frozen plasma, 3 units of cryoprecipitate, and 3 units of platelets. The plan was to keep her hemoglobin at 10 g/dl with ongoing transfusion as she continued to have massive postpartum hemorrhage of approximately 5 l. She had a Doppler ultrasound of the legs the same day, which did not reveal deep vein thrombosis. The Bakri balloon, vaginal pack, and subcutaneous drain were removed and inotropic support was withdrawn the following day with no evidence of further vaginal bleeding. The intra-peritoneal drain was removed on day 4 post-operatively. She had a transfemoral insertion of inferior vena caval (IVC) filter on day 3 to be left in permanently.
She was extubated on three occasions resulting in re-intubation as she would become agitated, hypoxic and hypertensive. On day 5, a whole body CT scan was performed which did not reveal any abnormal findings. A repeat echocardiogram was performed on day 6, suspecting a repeat pulmonary embolism due to her agitated status; this showed no evidence of thrombus and good biventricular function. She had a percutaneous tracheostomy on day 7 that was removed on day 10. She was alert and responsive on day 10, intravenous heparin was changed to subcutaneous heparin and she was transferred back to delivery suite.
Due to a fall in the room and some degree of confusion, she had a neurology review, which revealed no other concerns apart from left arm weakness. She held her baby in her arms for the first time on day 12 post-operatively. Mother and baby were then transferred to the transitional care unit.
A repeat CT scan of the head revealed no deficit or intracranial abnormality. She also had a follow-up in place with the physical disability team, neuropsychiatrist, hematologist, occupational therapist, health visitor and the obstetrician following discharge from hospital.
She was discharged on day 16 on Warfarin.
| Discussion|| |
Pulmonary embolism is the leading cause of maternal death following a livebirth.  Although some authors disagree, women who undergo a caesarean delivery may have a three- to nine-fold greater risk of pulmonary embolism compared with those who deliver vaginally. ,
Two-thirds of the patients who die from a pulmonary embolus do so within 30 min of the acute event.  Our case emphasizes the importance of timely echocardiography and prompt decision-making of this life-threatening condition. It also highlights that the presence of consultant obstetrician, anesthetist, and intensivist can greatly influence the speed of making challenging decisions for management and thereby helping to improve patient outcome. It is not easy to carry out a caesarean section with ongoing cardiopulmonary resuscitation, but our case demonstrated the calmness and organizational abilities of the surgical team.
The risk of thromboembolic disease in pregnancy is increased six-fold compared to the non-pregnant state. This could be due to a number of factors including poor blood flow in the legs due to the growing uterus and compression of the veins and acceleration of coagulation.  This risk is further increased by previous thromboembolism, obesity, lupus anticoagulant, immobilization and operative delivery.  Our patient had four risk factors for thromboembolic disease, namely she was pregnant, age was more than 35 years, she was undergoing surgery and had a family history of thrombosis.
A differential diagnosis of amniotic fluid embolism was considered, but ruled out by confirmation of the embolus on echocardiography.
We found two reported cases of cardiac arrest during caesarean section in the literature. In the first case, cardiac arrest occurred shortly after injection of Methylergometrine and Syntocinon. She received 100% oxygen, cardiopulmonary resuscitation and adrenaline. Shortly after this, irregular cardiac activity was noted.  Rescue thrombolysis with Reteplase was instituted in the second case of cardiac arrest.  As in our case, this lady also had severe uterine bleeding which was managed conservatively.
In a case of life-threatening cardiovascular or respiratory compromise due to pulmonary embolism during delivery, rescue thrombolysis is a possible option that may be worth considering. Systemic thrombolytic therapy is usually recommended if it is not contraindicated and the thrombi are demonstrated in more than one cardiac chamber, entailing a higher risk of surgical intervention.  However, the potential for massive obstetric bleeding and further side-effects must be considered and adequate strategies and resources should be available.
| References|| |
|1.||Jessurun GAJ, Brügemann J, Hamer JPM, Römer JPH, Lie KI. Thrombolytic therapy of right heart emboli-in-transit. Eur Respir J 1995;8:1834-7. |
|2.||Ros HS, Lichtenstein P, Bellocco R, Petersson G, Cnattingius S. Pulmonary embolism and stroke in relation to pregnancy: How can high-risk women be identified? Am J Obstet Gynecol 2002;186:198-203. |
|3.||Donaldson GA, Williams C, Scannel JG, Shaw RB. A reappraisal of the application of the Trendelenberg operation to massive fatal embolism: Report of a successful pulmonary-artery thrombectomy using a cardiopulmonary bypass. N Engl J Med 1963;268:171-4. |
|4.||Sjoberg F, Gupta A, Bengtsson M. Cardiac arrest during caesarean section. Int J Obstet Anesth 1993;2:174-6. |
|5.||Report on confidential enquiries into maternal deaths in the UK 1985-1987. London: HMSO; 1991. |
|6.||Wenk M, Popping DM, Hilyard S, Alber H, Mollmann M. Intraoperative thrombolysis in a patient with cardiopulmonary arrest undergoing caesarean delivery. Anaesth Intensive Care 2011;39:671-4. |
|7.||Ercan E, Tengiz I, Sekuri C, Sahin F, Aliyev E, Akin M, et al. Cardiac thrombi in a patient with protein-C and S deficiencies: A case report. Thromb J 2004;2:2. |