From Uterus to Pulmonary Embolus

Abstract

A 36-year-old Afro-Caribbean woman presented with recurrent syncope and shortness of breath after a long-haul flight. On admission, ECG revealed sinus tachycardia at 130 bpm and mildly flattened T waves in V2 through V5 (Figure 1a). D-Dimers were elevated (663 ng/mL), and blood gases showed hypoxia. Chest x-ray was unremarkable (Figure 1b). Family history revealed that the patient’s mother had suffered a previous deep venous thrombosis. Figure 1. a, ECG showing sinus tachycardia and mildly flattened T waves in V2 through V5. b, Chest x-ray with unremarkable findings. The initial clinical presentation was consistent with pulmonary embolism, confirmed by computed tomographic scan that showed a large saddle-shaped embolus in the pulmonary trunk extending into the right main pulmonary artery (Figure 2a), the right ventricle, the right atrium, and the inferior vena cava (IVC). There was also a smaller extension into the left main pulmonary artery as well as smaller, segmental, and subsegmental thrombi. Figure 2. a, Contrast-enhanced pulmonary computed tomography on admission showing a large saddle embolus in the pulmonary trunk and right main pulmonary artery. b, Contrast-enhanced pulmonary computed tomography after the first thrombolytic treatment showing resolution of the large saddle-shaped embolus in the pulmonary trunk and right main pulmonary artery. Given the extensive radiological findings along with clinical deterioration, the patient received a thrombolytic regimen with streptokinase. A repeat scan 12 hours after initiation of thrombolytic therapy showed that the saddle-shaped embolus in the pulmonary trunk had resolved (Figure 2b), but thrombotic elements in the right heart cavities and the IVC remained. An echocardiogram confirmed the presence …