Abstract
Pregnancy and peripartum period leads to Virchow’s triad (hypercoagulability, venous stasis and vascular injury) thereby increasing the risk of thromboembolism by many folds in these patients. Accurate diagnosis of peripartum pulmonary embolism is pertinent for reducing morbidity and mortality. Accurate diagnosis is also vital for avoiding the adverse effects of unwanted anticoagulation in pregnant mother and fetus in a patient wrongly diagnosed with this condition. Computerized tomographic pulmonary angiography has a high specificity and sensitivity in comparison to ventilation/perfusion scan for diagnosis of peripartum pulmonary embolism (PPE). It has a lower fetal radiation exposure and aids in arriving at an alternative diagnosis, if PPE is absent. Low molecular weight heparin is the medication of choice in the treatment of peripartum pulmonary embolism. Thrombolysis is considered in patients with massive PPE and hemodynamic instability, refractory hypoxia or right ventricular dysfunction. Regional anesthesia/analgesia can be given safely in these patients. We report two cases of PPE and review the anesthetic and surgical consideration.
Highlights
Either congenital or acquired thrombophilia’s are the most important risk factor for the development of peripartum pulmonary embolism (PPE)
1) Age, the incidence of PE is double after 35 years [8]; 2) Parity: the risk of PE increases with the increase in parity, the risk is more after three pregnancies [8]; 3) obesity [8,9]; 4) operative delivery: up to 8 folds depending on emergency or elective procedure [9]; 5) Estrogen administration; 6) Pregnancy with heart disease, sickle cell disease, lupus, diabetes, hypertension and smoking; 7) Pregnancy complicated with multiple gestation, hyperemesis, peripartum hemorrhage, massive transfusion and the postpartum infection; 8) Thrombophilia is present in up to 50% of the women who had venous thromboembolism during pregnancy or in peripartum period [10]; 9) History of thrombosis is an important risk factor, recurrent episodes account for 15% to 25% of all thromboembolic events during pregnancy or peripartum period
If PE is diagnosed near the term, induction of labor and anticoagulation with unfarctionated heparin (UFH) is advised, as action of UFH is predictable and it can be reversed (Figure 2), UFH can be stopped once
Summary
Either congenital or acquired thrombophilia’s are the most important risk factor for the development of peripartum pulmonary embolism (PPE). During pregnancy the pro-coagulant factors, fibrinogen, factor v, vii, ix and x leading to the enhanced thrombin generation, at the same time activity of protein S is decreased and activated protein C resistance is increased The rate of pulmonary embolism (PE) in the peripartum period is fivefold higher in comparison to the same aged non-pregnant female [2] This increased risk of peripartum pulmonary embolism (PPE) is a combined effect of hypercoagulability, venous stasis and vascular injury. Peripartum pulmonary embolism (PPE) is one of the leading causes of maternal morbidity and mortality in developed countries. Pregnancy and peripartum period lead to Virchow’s triad (hypercoagulability, venous stasis and vascular injury) and increasing the risk of thromboembolism by many folds in these patients. We report two cases of PPE and review the anesthetic and surgical consideration
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