This case will illustrate some of the difficult decisions facing clinicians managing the pregnant patient with pulmonary embolism (PE).
An 18 year old woman at 30 weeks of an uncomplicated, first pregnancy presented to the emergency department complaining of abdominal pain. Physical exam was notable for right upper quadrant abdominal tenderness. Laboratory studies revealed a markedly elevated amylase and lipase. Abdominal ultrasound showed cholelithiasis. All fetal parameters were normal. She was admitted with the diagnosis of gallstone pancreatitis. Total parenteral nutrition was started, and she was placed on bed rest. Five days into her admission, she was noted to be dyspneic. Oxygen saturation of hemogloblin (SaO2) was 92% on room air. Computed Tomographic Angiogram of the chest (Figures 1 and 2) show multiple pulmonary emboli at the bifurcation of the right and left main pulmonary arteries. Bedside echocardiogram revealed a dilated and hypokinetic right ventricle. Enoxaparin was administered subcutaneously 1 mg/kg every 12 hours.DISCUSSION: There are several difficult questions facing the clinician in the management of PE in pregnancy, including the risk of radiation exposure to the fetus in diagnosing PE and the safety of anticoagulation and thrombolysis, especially if an emergent delivery is needed or for maternal hemodynamic collapse. Unfractionated and low molecular weight heparins have no known teratogenic effects and do not anticoagulate the fetus. Turrentine in 1995 reviewed 172 cases of women with pregnancy-associated venous thromboembolism treated with thrombolytics. Data on efficacy of these agents are culled from the literature on non-pregnant patients. More studies are necessary to elucidate guidelines for therapy in this population.
After one week of therapy, oxygenation and RV function normalized. A healthy boy was delivered electively at 33 weeks. The pancreatitis resolved after placement of a stent.
Arterial Blood Gas AnalysispH7.49PaCO229 mm HgPaO257 mm HgSaO292%
D. Kass, None.