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      Catheter-directed Pulmonary Artery Embolism Thrombolysis: A Life-saving Procedure for Postpartum Pulmonary Embolism: A Near-miss Case

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          ABSTRACT

          Aim

          This case aims to report how timely management with catheter-based thrombolysis was life-saving for a near-miss case of postpartum pulmonary embolism (PE).

          Background

          Near-miss cases describe women who underwent and overcame a serious medical condition while pregnant, giving birth, or after giving birth. During pregnancy and puerperium, there is an increase in the risk of deep venous thrombosis (DVT), PE, stroke, cerebral venous sinus thrombosis (CVST), etc., due to physiological changes that occur, resulting in a state of hypercoagulability.

          Case description

          A 35-year-old female presented in puerperium with dyspnea and chest discomfort of 12-hour duration. She had a full-term normal vaginal delivery 13 days ago. She was later diagnosed with PE and was treated successfully with catheter-directed thrombolysis.

          Conclusion

          Near-miss cases of PE require proficient assessment of the presentation, risk factors, and treatment options. As such, cases are associated with increased mortality when treatment is delayed. Due to the acute presentation of the patient, the decision for catheter-directed thrombolysis was made for immediate resolution of the thrombus. We believe this procedure was lifesaving in this situation and is an effective therapeutic choice in such scenarios.

          Clinical significance

          Acute PE is a catastrophic situation that is mostly seen in the postpartum period. The clinical picture of PE is nonspecific in pregnancy. It is associated with significant mortality in the absence of therapy. Thrombolysis has been utilized frequently with positive results.

          How to cite this article

          Sajjad S, Acharya N, Acharya S, et al. Catheter-directed Pulmonary Artery Embolism Thrombolysis: A Life-saving Procedure for Postpartum Pulmonary Embolism: A Near-miss Case. J South Asian Feder Obst Gynae 2023;15(3):335–337.

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          Most cited references6

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          Incidence, causes and correlates of maternal near‐miss morbidity: a multi‐centre cross‐sectional study

          SA Oppong, A A Bakari, AJ Bell … (2019)
          To explore the incidence and factors associated with maternal near-miss. Cross-sectional study with an embedded case-control study Three tertiary referral hospitals in southern Ghana All women admitted to study facilities with pregnancy-related complications or for birth. An adapted version of the WHO Maternal Near Miss Screening Tool was used to identify maternal near-miss cases. These were compared with unmatched controls (uncomplicated deliveries) in a ratio of 1:2. Incidence of maternal near-miss, maternal near-miss-maternal mortality ratio, and cause of and factors associated with maternal near-miss. Out of 8,433 live births, 288 maternal near-miss cases and 62 maternal deaths were identified. 454 healthy controls were recruited for comparison. Maternal near-miss and maternal death incidence ratios were 34.2 (95% CI:30.2 – 38.1) and 7.4 (95% CI:5.5 – 9.2) per 1000 live births respectively with a maternal near-miss-mortality ratio of 4.6:1. Cause of near-miss was preeclampsia/eclampsia (41.0%), haemorrhage (12.2%), maternal sepsis (11.1%), and ruptured uterus (4.2%). Major factor associated with maternal near-miss was maternal fever within the seven days before birth (OR:5.95 95%CI:3.754 – 9.424). Spontaneous onset of labor was protective against near miss OR:0.09 95% CI: 0.057 – 0.141) For every maternal death, there were nearly five maternal near-misses. Women having a fever in the seven days prior to delivery were six times more likely to experience a near-miss than women not having fever. Maternal near-miss exceed maternal death by 5:1, with the leading cause of maternal near-miss was preeclampsia/eclampsia.
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            Efficacy and Safety of Flow-Directed Pulmonary Artery Catheter Thrombolysis for Treatment of Submassive Pulmonary Embolism

            Ron Gaba, Madhu S. Gundavaram, Ahmad Parvinian … (2014)
            Article 0 comments Cited 5 times – based on 0 reviews     Review now
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              Intrapulmonary artery infusion of urokinase for treatment of massive pulmonary embolism: a review of 26 patients with and without contraindications to systemic thrombolytic therapy.

              C.J. Mccotier, K.S. Chiang, E.L. Fearrington (2009)
              Pulmonary emboli (PE) are a common event seen in over 600,000 patients a year. Occurring suddenly, PE often result in a high rate of mortality. To combat the high rate of mortality, more aggressive therapies including the use of thrombolytics are often indicated. The use of intrapulmonary artery infusion of urokinase has been shown to promote rapid resolution of emboli and restoration of normal pulmonary hemodynamics. The study was undertaken to review the effectiveness and safety of pulmonary artery infusion of urokinase in 26 patients with and without contraindications to the use of systemic thrombolytic therapy. We reviewed the outcomes of 26 patients who received infusion of urokinase, using a usual loading dose of 4,000 U/kg body weight given as a bolus, followed by 4,000 U/kg/h for 12 to 24 h, using either/or unilateral or bilateral infusions. Pulmonary angiograms were obtained prior to and following the urokinase infusions. Intrapulmonary artery infusion of urokinase was given to 26 patients, 9 of whom had contraindications to the use of systemic thrombolytic therapy. Six patients were recent post operative, one was receiving oral anticoagulants, one was receiving chemotherapy with bleeding complications, and one had received cardiopulmonary resuscitation. Twenty of the patients returned to their baseline state (normal heart rate, blood pressure, and p02), one was minimally improved, and five deaths occurred. Of the five deaths, three occurred within 1 h of starting urokinase infusion, the remaining two died more than 36 h after treatment with urokinase as a result of their basic underlying disease. Minor bleeding occurred from puncture sites, two hematomas occurred at the puncture site, and there were two gastrointestinal bleeds, one of which occurred a week post urokinase therapy while the patient was receiving heparin and coumadin. No central nervous system bleeds occurred and no transfusions were required as a result of urokinase intrapulmonary artery infusions. The overall mortality rate in this series was 11.5%. Intrapulmonary artery infusion of urokinase in extensive pulmonary embolism is a safe and efficient treatment in patients with and without contraindication to the use of systemic thrombolytic therapy. With a usual loading dose of 4,000 U/kg body weight, followed by an infusion of 4,000 U/kg/h for 12 to 24 h, it produces significant and rapid resolution of pulmonary emboli with a low morbidity and mortality rate. In our series, the mortality rate was 11.5%, and none of the deaths was the direct result of urokinase therapy.
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                Author and article information

                Contributors
                Journal
                Journal ID (publisher-id): JSAFOG
                Title: Journal of South Asian Federation of Obstetrics and Gynaecology
                Abbreviated Title: JSAFOG
                Publisher: Jaypee Brothers Medical Publishers
                ISSN (Print): 0974-8938
                ISSN (Electronic): 0975-1920
                Publication date (Print): May-June 2023
                Volume: 15
                Issue: 3
                Pages: 335-337
                Affiliations
                [1 ]Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Nagpur, Maharashtra, India
                [2,3,5,6 ]Department of Obstetrics and Gynaecology, Datta Meghe Institute of Higher Education and Research, Nagpur, Maharashtra, India
                [4 ]Department of Interventional Radiology, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
                Author notes
                Sheeral Sajjad, Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Nagpur, Maharashtra, India, Phone: +91 9689686799, e-mail: sheeralsajjad@ 123456hotmail.com
                Article
                DOI: 10.5005/jp-journals-10006-2231
                SO-VID: 1138e9be-8d8d-4b83-96b9-1c45f5c3317f
                Copyright © Copyright © 2023; The Author(s).
                License:

                © The Author(s). 2023 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 11 March 2023
                Date accepted : 15 April 2023
                Date: 31 July 2023
                Categories
                Subject: CASE REPORT
                Custom metadata
                file-pdf jsafog-15-335.pdf

                ScienceOpen disciplines: Obstetrics & Gynecology
                Keywords: Thrombolysis,Hypercoagulability,Puerperium,Pulmonary embolism,Venous thromboembolic events
                Data availability:
                ScienceOpen disciplines: Obstetrics & Gynecology
                Keywords: Thrombolysis, Hypercoagulability, Puerperium, Pulmonary embolism, Venous thromboembolic events

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