OP-15 Case report pulmoner embolism during pregnancy

Objective

Thrombosis is limited to the deep veins of the lower extremities in most cases during pregnancy. In this case, a rare arterial embolism (in the left anterior tibial artery) was observed. A 36-year-old 33-week pregnant woman patient with a history of G3P2 2*CS was admitted into ALKU Hospital due to dyspnea and tachycardia. Pulmonary embolism is a mortal condition seen in 1/7000 pregnancies. There is clinical evidence of DVT in 70% of women who develop pulmonary embolism.

Case

A 36-year-old 33-week-old pregnant woman applied to the emergency department with complaints of high fever, left flank pain and shortness of breath. Patient’s vitals: TA:135/70 mmHg, Pulse:170/min, Fever:39C, Spo2:91. Laboratory results were: D-dimer: 10520 ng/ml, Procalcitonin: 2.68 ng/dl. Celestone(1x2 amp), Rocephin(1 gr IV), Diltiazem(100cc/hour) were applied to the patient. Oxygen was started at 4lt/min. Sinus tachycardia was seen on ECG and EF was 65% on ECO. No significant dilatation was observed in the right heart structures. Considering the clinical and laboratory evaluation of the patient, it was thought to be compatible with the preliminary diagnosis of pulmonary embolism. The patient was started on Clexane 2x0,6. Due to that the patient’s vital signs were unstable, the partial oxygen pressure was at the intubation limit, and the maternal-fetal tachycardia did not improve, the patient was taken to cesarean section. Postoperative vitals and general condition was good. As a result of thorax CT angiography, there were thickenings in the interstitial septas and frosted glass densities in the bilateral lungs, and the patient was transferred to the chest diseases service with a preliminary diagnosis of alveolar hemorrhage. There was an appearance compatible with thrombosis in the left tibial artery’s branch. On the 14th postoperative day, the patient’s vital signs were stable, the laboratory values were Troponin- negative(less than 0,04 ng/ml), D-dimer (less than 500 ng/ml) Procalcitonin:0.14 ng/dl. One week after discharge, the patient presents to the emergency department again with complaints of fever and flank pain. Sepsis was suspected in the patient who had fever(39C), tachycardia(130/min) and Spo2: 89. After further investigations(CT imaging), the Urinoma secondary to renal pelvis laceration due to nephrolithiasis was considered as the cause of sepsis. Double J stent was inserted to the patient by the urology team under cystoscopy. As soon as the patient’s urinoma and sepsis regressed after antibiotic therapy, the stent was removed on the postoperative 30th day.

Discussion

Considering similar complaints during pregnancy, sepsis and other pulmonary diseases of pregnancy must be ruled out. Urosepsis is a common cause of septic shock during pregnancy. Genitourinary tract infections can often be asymptomatic. It may be accompanied by nephrolithiasis.

Conclusion

The risk of thrombosis and pulmonary embolism increases during pregnancy and puerperium. Especially pregnant women with a history of thrombosis should be questioned and anticoagulant treatment should be started.

Keywords

Pregnacy, pulmoner embolism, thrombosis

1. Paul E Marik, Lauren A Plante et al. Venous thromboembolic disease and pregnancy. N Engl J Med. 2008 Nov 6;359(19):2025-33. 
2. Victor A Rosenberg, Charles J Lockwood et al. Thromboembolism in pregnancy. Obstet Gynecol Clin North Am. 2007 Sep;34(3):481-500, xi.