Table 2 Summary of peripartum pulmonary embolism over the past last 10 years in the literature
Authors/year | Maternal age (yo) Gravida, parity | Gestational age | Medical history, risk factors | Mode of birth delivery | Indication for CS | Mode of anesthesia | Presentation/Onset | Management | Hypothesis | Identified diagnosis | Outcomes |
|---|---|---|---|---|---|---|---|---|---|---|---|
Ho et al. (2014) [25] | 37 yo G2P1 | 37w 2d | None | Emergent CS | Nonreassuring fetal heart rate | - | -Bilateral limb weakness, consciousness disturbance -Unstable hemodynamic status, hypotension (46/20 mmHg), tachycardia (121 beats/minute), low oxygen saturation (85%), tachypnea (32 breaths/minute), hypoxemia, and respiratory alkalosis | -CPR - Venoarterial ECMO - Emergent catheter-directed thrombectomy - Continuous low molecular weight heparin (LMWH) infusion, stopped later due to hemoperitoneum hemorrhage | - | Massive PE | - Alive - Full recovery - Transferred to a general ward for observation |
Van Liempt et al. (2015) [35] | 40 yo | 35w 2d | none | CS | Vaginal bleeding/placenta previa | Spine anesthesia | Asystole occurred during uterotomy | CPR and fetal delivery | -Bezold Jarisch reflex -Amniotic fluid embolism -Venous air embolism | None | -Recovery in 48 h -Alive |
Wang et al. (2015) [36] | 24 yo | 40w 4d | none | -VB -PAS Conservative management with uterine arterial embolism, hysteroscopic resection, and mifepristone | - | - | -Dyspnea and loss of consciousness -Acute respiratory distress syndrome | CPR | - | Acute trophoblastic PE and allergic shock when infusing povidone-iodine | Death |
Yufune et al. (2015) [37] | 38 yo | 38w 1d | Frequent transient ischemic attacks during hyperventilation associated with Moya Moya disease | CS | A previous cesarean section and Moya Moya disease | General anesthesia | -Massive vaginal bleeding without clotting - Disseminated intravascular coagulation -Hypovolemic shock -Cardiac arrest | -Blood volume replacement -Coagulation therapy (fresh frozen plasma, platelets, fibrinogen, antithrombin concentrate) -Emergency relaparotomy -CPR | - | Amniotic fluid embolism | alive |
Pandy et al. (2015) [27] | 35 yo | - | Obese | CS | - | - | A syncopal attack following cesarean delivery | - | - | Pulmonary embolism | - |
Colombier et al. (2015) [23] | 36 yo | 36w | None | Emergent cesarean delivery | Pathologic cardiotocography after spontaneous membrane rupture | Epidural anesthesia | -Hemodynamically unstable, presenting severe bradycardia and hypotension, followed by cardiac arrest and active intra-uterine bleeding after 30 min from CS -Echocardiography revealed a severe right heart dysfunction and massive dilatation - CT scan of the lungs confirmed the diagnosis of PE and showed an occlusion of the segmental and sub-segmental pulmonary arteries | -CPR -Emergency surgical pulmonary embolectomy -Followed by a hysterectomy | - | massive bilateral PE | -Alive -Follow-up at 3 months showed a persistent right ventricular dilatation and moderate dysfunction -Patient complained a persistent slight dyspnea at physical effort (NYHA II) |
Ahn et al. (2016) [38] | 35 yo | Term | None | CS | - | - | -Dyspnea -Hypotension in 24 h after CS | Embolectomy | - | Massive bilateral pulmonary thromboembolism | Alive |
Umazume et al. (2017) [39] | 28 yo | 37w 3d | BMI 23.6 kg/m2 | CS | Placenta previa | Combined spinal and epidural analgesia | Hypoxemic | CPR | Amniotic fluid embolism | Transient bronchospasm and pulmonary hypertension | Alive |
Oda et al. (2018) [40] | 25 yo | 38w 4d | none | CS | Repeat CS | Spinal anesthesia | Dyspnea, hypotension, and loss of consciousness with decreased peripheral oxygen saturation after removal of the placenta | - Tracheal intubation and mechanical ventilation with oxygen -Heparin | - | Pulmonary embolism caused by ovarian vein thrombosis extending up to the inferior vena cava | -Recovery in 1 day -Alive |
Tong et al. (2019) [41] | 27 yo | 40w | Residual placenta | VB | - | - | Fever and dyspnea after delivery | -Antibiotics -Low molecular weight heparin -Warfarin -Mifepristone, then hysteroscopy | - | Pulmonary embolism | Alive |
Finianos et al. (2021) [42] | 37 yo Multiparous | 31w | Ovarian vein thrombophlebitis Uterine fibroid | CS | Repeat CS following preterm rupture of membranes | - | Severe abdominal pain, fever, and chills | -Therapeutic anticoagulation with low molecular weight heparin - Antibiotic | - | Subsegmental pulmonary embolism | Alive |
Tiwary et al. (2022) [43] | 37 yo | - | BMI = 28 kg/m2 American Society of Anesthesiologist physical status II | Emergency LSCS | - | - | Desaturation Tachypnea | Therapeutic anticoagulation using low-molecular-weight heparin (enoxaparin) | - | Bilateral pulmonary embolism | alive |
Wu et al. (2022) [44] | 32 yo | 39w 6d | IVF subclinical hypothyroidism | CS | Requirement | - | -Shortness of breath after activity after 14 days of delivery -D-dimer was 7440 ng/mL | -Anticoagulation with low molecular weight heparin (LWMH) | - | Pulmonary embolism | -Recovery in 1 week -Alive |
Wu et al. (2022) [44] | - | 37w 4d | GDM; breast fibroma; recurrent shortness of breath | CS | Requirements and chest tightness | - | Paroxysmal chest tightness, shortness of breath, discomfort, slight cough after 18 days of delivery - D-dimer was 1500 ng/mL | -Anticoagulation therapy immediately by subcutaneous injection of Enoxaparin 4100 IU twice daily | - | Pulmonary embolism | Alive |
Zhang et al. (2022) [45] | 25 yo Nulliparous | 40w 4d | None | Emergency CS | Retention of fetal head descending and persistent occipito-posterior position | Combined spinal-epidural anesthesia | Cough hypotension, tachycardia, hypoxemia, dyspnea, cyanotic after the end of CS 2 min | Resuscitation | Amniotic-fluid embolism | - | Alive |
Karakosta et al. (2023) [26] | 39 yo G5P2 | 37w 5d | BMI 26.5 kg/m2 ASA II | CS | Repeat cesarean section | General anesthesia | Sudden drop in end-tidal CO2 after placenta delivery combined with significant hemodynamic instability | -Thrombolysis by recombinant tissue plasminogen activator under continuous -US monitoring, Bakri balloon placement, and rescue hysterectomy | - | Acute pulmonary embolism | Alive with the removal of the uterus |
Zawislask et al. (2023) [46] | 40 yo G8P9 | 39w | none | CS | Pulmonary embolism | General anesthesia | Dyspnea, shortness of breath, and chest pain Hypotension Tachycardia Hypoxemia, tachypnea, high D-dimer levels of 17,189 ng/ml before CS | -Unfractionated heparin monitored with activated partial thromboplastin time -CPR -Emergency pulmonary embolectomy in extracorporeal circulation | - | Massive central pulmonary embolism | -Recovery in 3 days - Alive |
Song et al. (2023) [28] | 31 yo G1P1 | 39w 4d | A dilated left ventricle with a patent foramen ovale | Planned CS | Macrosomia and separation of the symphysis | Spinal anesthesia at L3 to L4 | -Dyspnea and dull pain in the left back after surgery -Significantly elevated D-dimer (4.359 mg/L) - a blood clot in the left common iliac vein | -Low-molecular-weight heparin -Catheter-directed thrombus fragmentation and thrombolysis -combined anticoagulant therapy | - | Postpartum pulmonary embolism from iliac vein thrombosis | -Alive -Recovery after 6 months of follow-up |
Park et al. (2023) [24] | 36 yo G3P2, once CS | 35w 4d | Obesity (BMI = 34.6 kg/m2) | Emergent CS | Fetal tarchycardiac | General endotracheal anesthesia | -Drowsy, SpO2: 77% - Cardiac arrest - CT pulmonary angiography after cardiopulmonary securement was performed to confirm PE | - CPR - VA ECMO - surgical thrombectomy | - | Massive PE | -Alive -Discharge on day 50 - Follow-up was stopped 20 months after thrombectomy |
Krawczyk et al. (2023) [7] | 34 yo G3P2 | 24w4d Dichorionic twin pregnancy | WHO class III obesity (BMI = 44 kg/m2) | CS | Subchorionic hematoma and suspicion of placental abruption | General anesthesia | -An episode of sinus tachycardia (160 bpm) with a blood pressure drop to 90/50 mmHg -Cardiac arrest was confirmed 10 min after the delivery - Uterine atony and severe hemorrhage | - CPR - Heparin i.v -Postpartum hysterectomy -Blood transfusion | -Massive pulmonary embolism - Amniotic fluid embolus | CT pulmonary angiography was done without filling defect suggesting pulmonary embolism | -Alive -Both mother and twin newborn were discharged on day 3 |
24 yo G2P2 once CS | 28w | WHO class II obesity (BMI 36.7 kg/m2), immobilization, thrombophilia | Emergent CS | Premature abruption of the placenta after fetal surgery for placing vesicoamniotic intrauterine shunt | Spinal anesthesia | -Dyspnea, chest pain, and presented cyanosis - Sinus tachycardia 120/min - Cardiac arrest | - Heparin i.v - CPR - Actilyse - Oral warfarin -Blood transfusion | Suspected PE | CT pulmonary angiography was done without filling defect suggesting pulmonary embolism | -Alive -Both mother and baby were sent home on day 23 | |
Urriago-Osorio et al. (2023) [18] | 24 yo G3P2 | 26w | - | - | - | - | - Unconscious, diaphoretic, and cold, with subsequent partial recovery of consciousness, and after collapsing three times - Stuporous, diaphoretic, and cold, with a blood pressure of 60/28 mmHg and a heart rate of 155 bpm | - Vasopressor therapy -LMWH (enoxaparin 60 mg subcutaneously every 12 h) -Thrombolytic therapy with alteplase 100 mg intravenously | Point of care ultrasound (POCUS) revealed a suspected PE | Massive PTE | recovery and alive |
The present case | 36 yo | -37w2d -G3P1 once CS | -Advanced maternal age -Placenta previa | Emergent CS | Labor, vaginal bleeding in pregnancy with placenta previa | General anesthesia | Sudden cardiopulmonary collapse immediate after placental delivery | -CPR -blood transfusion - Anti-coagulant therapy -Multidisciplinary assessment -Interhospital management | -AFE -APE | US and CT angiopathy showed APE | -Alive -Recovery after 2w without severe sequela |