Robert Nichols DO Embolism Pulmonary Embolism Venous Air Embolism Amniotic Fluid embolism Embolism One of the leading causes of maternal mortality Noncardiovascular diseases 153 Cardiovascular diseases 147 ID: 606687
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Slide1
Embolism during Pregnancy
Robert Nichols, DOSlide2
Embolism
Pulmonary Embolism
Venous Air Embolism
Amniotic Fluid embolismSlide3
Embolism
One of the leading causes of maternal mortality
Non-cardiovascular diseases, 15.3%.
Cardiovascular diseases, 14.7%.
Infection or sepsis, 12.7%.
Hemorrhage, 11.3%.Cardiomyopathy, 10.8%.Thrombotic pulmonary embolism, 9.0%.Hypertensive disorders of pregnancy, 7.6%.Cerebrovascular accidents, 6.5%.Amniotic fluid embolism, 5.7%.Anesthesia complications, 0.2%.www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.htmlSlide4
Pulmonary Embolism
Difficult diagnosis and management
2 patients at risk
Overdiagnosis
results in unnecessary and often dangerous treatments to both patients
Usual imaging modalities must be considered with developing fetusSlide5
Pulmonary Embolism
Higher risk 2/2
Virchows
triad
Hypercoagulability
Vascular damageVenous stasisDVT occurs approximately 3x more frequently than PEDVT occurs on left leg in 85% of casesLikely due to compression of iliac vein by iliac artery and gravid uterusIsolated pelvic DVT is also much more common in parturientsSlide6
Pulmonary Embolism
ACOG guidelines to diagnosis
Diagnosis
often
difficult
D-Dimer unreliable in pregnant patientsRisk of radiation exposure in pregnancy must be consideredSlide7
Treatment
LMWH is treatment of choice in early pregnancy
Can be given as outpatient
Do not cross placenta and are is not secreted in breastmilk
1mg/kg q12
IV unfractionated heparin preferred near delivery and in renal failureAble to reverse urgently if neededAlso does not cross placenta or go into breastmilkBolus 80u/kg followed by 18u/kg/h, titrated to achieve therapeutic aPTT If SC initial dose is 17,500 units then titrated to aPTTThrombolytic drugs appropriate in hemodynamically unstable or hypoxicFetal loss vs. maternal deathWarfarin teratogenic and generally contraindicated in pregnant patientSlide8
Venous Air Embolism
Entrapment of air or medical gases into venous system causing symptoms and signs of pulmonary vessel obstruction
1% of maternal deaths
Incidence varies WIDELY depending on the source
Depends on surgical position, diagnostic tools Slide9Slide10
Pathophysiology
Vascular access and gradient between injury site and right heart must be present for VAE to occur
Determined by rate, volume, duration, patient position, type of
gas
Pulmonary vessels can filter most air emboli from venous
circulationLarger emboli can cause a variety of symptomsSlide11
Risk Factors VAE
Trendelenburg position
Placental abruption
Placenta
previa
Exteriorization of uterusManual placental extractionSevere preeclampsiaAntepartum hemorrhagehypovolemiaSlide12
Diagnosis
Know clinical signs and symptoms
May manifest as chest tightness or short breath with or without hypotension or decreased oxygen saturation in conscious patients
Variety of
diagnositic
toolsSlide13
Treatment
Inform Surgeon
Adequate hydration
Prevent further gas entry
Flood surgical field
Remove origin of gas entryIncrease right atrial pressure and trap air in right atriumReverse Trendelenburg when possibleLeft lateral recumbent positionDiscontinue N2O and ventilate with 100% oxygenAttempt to aspirate air through central line when appropriateResuscitateFluid administrationInotropes, vasopressor, pulmonary vasodilatorsCPR if necessaryHyperbaric oxygen when appropriateSlide14
Amniotic fluid embolism
5.7% of pregnancy related deaths in United States in 2011-12
Poorly understood
Diagnosis traditionally made at autopsy when fetal squamous cells are found in pulmonary circulation
Diagnosis of
exclusionMortality of AFE approaches 80%50% die within the first hour of onset of symotomsSlide15
AFE Pathophysiology
Theorized that amniotic fluid and cells enter circulation and trigger anaphylactic reaction
Fetal material not always found in patients with AFE and fetal material found in patients who did not trigger anaphylaxis
Currently believed that fluid or some other substance enters maternal circulation and triggers anaphylactic reaction OR activates complement cascade OR both.
Occurs in 2 phases
1. pulmonary artery vasospasm with pulmonary hypertension and elevated right ventricular pressure which causes hypoxia. Hypoxia causes myocardial and pulmonary capillary damage, left heart failure and ARDS.2. Those who survive phase 1 have hemorrhagic phase with massive hemorrhage with uterine atony and DIC; however, fatal consumptive coagulopathy may be the initial presentationSlide16
AFE risk factors
Multiparity
Advanced maternal age
Male fetus
Trauma
AbruptionPreviaNon-Hispanic black women have more than 2x risk of AFEWomen with cerebrovascular disease have 25x riskCardiac disease have 70x risk!Slide17
Treatment
Supportive
Early resuscitation
Pulmonary edema common – fluid input and output must be closely monitored
Left heart failure treated with
ionotropesCase reports show successful outcomes with hemodialysis with plasmapheresis and ECMO with intra-aortic balloon pumpDIC treated with blood components. Consider activated factor VIIa for severe hemorrhage2 cases report success with bilateral uterine artery embolization Slide18
References
Panting-Kemp A, Geller SE, Nguyen T, Simonson L,
Nuwayhid
B, Castro L. Maternal deaths in an urban perinatal network,
1992-1998
. Am J Obstet Gynecol. 2000;183:1207-1212.Chan WS, Ray JG, Murray S, Coady GE, Coates G, Ginsberg JS. Suspected pulmonary embolism in pregnancy: clinical presentation, results of lung scanning, and subsequent maternal and pediatric outcomes. Arch Intern Med. 2002;162:1170-1175. Einstein AJ, Henzlova MJ, Rajagopalan S. Estimating risk of cancer associated with radiation exposure from 64-slice computed tomography coronary angiography. JAMA. 2007;298:317-323http://www.acog.org/~/media/Districts/District%20VIII/PulmonaryEmbolismPregnancy.pdf?dmc=1&ts=20140525T0200225053Kim, Chang Seok et al. “Venous Air Embolism during Surgery, Especially Cesarean Delivery.”
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