Krawczyk Paweł, Huras Hubert, Jaworowski Andrzej, Tyszecki Paweł, Kołak Magdalena
Department of Anesthesiology and Intensive Care Medicine, Jagiellonian University Medical College, Krakow, Poland.
Department of Obstetrics and Perinatology, Jagiellonian University Medical College, Krakow, Poland.
Ann Palliat Med. 2023 Jan;12(1):219-226. doi: 10.21037/apm-22-435. Epub 2022 Sep 9.
Massive pulmonary embolus (PE), resulting in cardiac arrest during pregnancy and postpartum, is a rare but potentially catastrophic event. The most severe manifestation of massive PE is cardiovascular instability, including cardiogenic shock and cardiac arrest requiring intensive care unit (ICU) admissions. Up to 23% of high-risk PE pregnant and postpartum patients experience cardiac arrest.
Case 1, a 34-year-old obese patient, with a twin pregnancy, had cesarean sections in the 24th week of pregnancy due to premature abruption of the placenta. Immediately after the birth, she experienced a sudden cardiac arrest. Treatment was initiated in line with antimicrobial lock solutions (ALS), heparine and alteplase was administered due to suspected massive pulmonary embolism. After 20 minutes from return of spontaneous circulation (ROSC), the uterine atony and severe hemorrhage occurred, and a postpartum hysterectomy was performed. The mother and two daughters are alive in 2021. Case 2, a 24-year-old obese patient had a cesarean section due to abruption of the placenta in the 28th week of pregnancy. Twelve hours after cesarean delivery, the patient's condition suddenly deteriorated. The patient reported dyspnea, chest pain, and presented cyanosis. The blood pressure was 66/30 mmHg, heart rate 130/min, tachypnea with a respiratory rate of 30/min, saturation 80% on air. High flow oxygen via face mask with reservoir (FiO2 0.85) and ephedrine 2×10 mg i.v. were administered. Due to suspected pulmonary embolism, a bolus of 5,000 IU of heparin was administered iv. Despite the implemented measures, cardiac arrest was confirmed with the initial rhythm of pulseless electrical activity (PEA) (sinus tachycardia 120/min). Treatment consistent with ALS was initiated. Due to the high probability of pulmonary embolism, a bolus of alteplase was administrated. ROSC was obtained 7 minutes later. Because of obstetric hemorrhage hysterectomy was performed. The mother and the baby are alive in 2022.
In light of current evidence, presented data suggest that early and aggressive recombinant thrombolytic use in case of cardiac arrest and suspected PE in obstetric patients may be life-saving, effective treatment with a good neurological outcome. Major bleeding complications should be anticipated when administering this therapy.
大面积肺栓塞（PE）导致妊娠和产后心脏骤停是一种罕见但可能具有灾难性的事件。大面积PE最严重的表现是心血管不稳定，包括心源性休克和需要入住重症监护病房（ICU）的心脏骤停。高达23%的高危PE妊娠和产后患者会发生心脏骤停。
病例1，一名34岁的肥胖双胎妊娠患者，因胎盘早剥在妊娠第24周行剖宫产。产后立即发生心脏骤停。按照抗菌封管液（ALS）进行治疗，因怀疑大面积肺栓塞给予肝素和阿替普酶。自主循环恢复（ROSC）20分钟后，出现子宫收缩乏力和严重出血，遂行产后子宫切除术。2021年，母亲和两个女儿均存活。病例2，一名24岁的肥胖患者因妊娠第28周胎盘早剥行剖宫产。剖宫产术后12小时，患者病情突然恶化。患者自述呼吸困难、胸痛，并出现发绀。血压66/30 mmHg，心率130次/分，呼吸急促，呼吸频率30次/分，空气中饱和度80%。通过带储氧袋的面罩给予高流量氧气（FiO2 0.85）并静脉注射2次麻黄碱，每次10 mg。因怀疑肺栓塞，静脉注射5000 IU肝素。尽管采取了这些措施，但最初心律为无脉电活动（PEA）（窦性心动过速120次/分），确认发生心脏骤停。开始按照ALS进行治疗。由于肺栓塞可能性高，给予一剂阿替普酶。7分钟后恢复自主循环。因产科出血行子宫切除术。2022年，母亲和婴儿均存活。
根据现有证据，所呈现的数据表明，对于产科患者心脏骤停且怀疑PE的情况，早期积极使用重组溶栓药物可能是挽救生命且有效的治疗方法，神经功能预后良好。应用该疗法时应预见到主要出血并发症。
