Pulmonary embolism during cesarean section in a patient with severe pulmonary hypertension

Abstract Background: Pulmonary embolism (PE) is a relatively common health problem and the third most common cause of cardiovascular death with a 15-20 percent mortality rate. Severe pulmonary arterial hypertension is not common in acute forms of the disease, and we usually expect only mild to moderate degrees of PAH in these patients. However, we have encountered numerous cases of severe pulmonary hypertension after acute PE in our practice. In this study, we aimed to evaluate the echocardiographic findings of patients admitted with documented PE in a 5 years study of two heart centers of Urmia.Methods: In this retrospective study, the data of 183 patients with a definitive diagnosis of acute pulmonary embolism based on pulmonary CT angiography have entered the study.Results: Of the 183 cases diagnosed with pulmonary embolism with an average age of 61.15 years, 45.4% were male and 54.6% were female. Shortness of breath, chest pain, and hemoptysis were seen in 88%, 49.2%, and 13.1% of patients, respectively. Tachypnea and tachycardia were the most common clinical findings with a frequency of 54.1%. Echocardiographic findings of right ventricular enlargement and right ventricular dysfunction were observed in 66.7% and 67.8% of patients, respectively and 42.1% of patients had severe pulmonary hypertension. We found a significant relationship between pulmonary artery pressure severity and shock state as well as in-hospital mortality. While only 3 patients out of 64 cases (4%) with normal or mildly elevated pulmonary artery pressure died in their hospital stay period, the mortality rate was 28.5% in patients with moderate or severe pulmonary artery hypertension (p-value=0.002).Conclusion: we found a relatively high frequency of severe pulmonary artery hypertension in patients admitted with the definite diagnosis of acute pulmonary embolism and there was a significant correlation between pulmonary artery pressure severity and shock state, as well as in-hospital mortality. So, echocardiographic findings including right ventricular systolic pressure and TR velocity may have additional prognostic value in the decision making of acute PE patients and could be helpful in reducing in-hospital mortality of this complex illness provided being included in prognostic models of acute PE, based on future studies.

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Atrial Septal Defect dengan Hipertensi Pulmonal Berat yang Dijadwalkan untuk Seksio Sesarea

Jurnal Anestesi Obstetri Indonesia ◽

10.47507/obstetri.v1i1.24 ◽

2020 ◽

Vol 1 (1) ◽

pp. 33-9

Author(s):

Muhammad Rodli ◽

Isngadi Isngadi

Keyword(s):

Blood Pressure ◽

Pulmonary Hypertension ◽

Cesarean Section ◽

Atrial Septal Defect ◽

Epidural Anesthesia ◽

Congenital Heart ◽

Septal Defect ◽

Severe Pulmonary Hypertension ◽

Central Venous ◽

Congenital Diseases

Kelainan jantung kongenital dan sistem kardiovaskular terjadi pada 7 sampai 10 per 1.000 kelahiran hidup (0,7%–1,0%). Penyakit jantung kongenital adalah bentuk penyakit bawaan yang paling umum dan sekitar 30% dari semua kejadian penyakit bawaan. Cacat jantung kongenital yang paling sering terabaikan pada masa kanak-kanak adalah Atrial Septal Defect (ASD) sekundum. Resiko operasi non-jantung akan meningkat jika ditemukan gagal jantung, hipertensi pulmonal dan sianosis. Dilaporkan kasus primigravida berumur 33 tahun, dengan usia kehamilan 32–34 minggu yang menjalani seksio sesarea. Pada pemeriksaan fisik didapatkan nadi 100 x/menit (reguler), tekanan darah 115/74 mmHg, saturasi oksigen 90-94% dengan suplemen oksigen 10 L/menit, edema pada kedua tungkai, tekanan vena jugular (JVP) tidak meningkat. Hasil laboratorium dalam batas normal. Hasil echocardiografi menunjukkan adanya ASD sekundum (berdiameter 2–3 cm), bidirectional shunt dominan kanan ke kiri (sindroma Eisenmenger), regurgitasi trikuspid, hipertensi pulmonal berat dengan perkiraan tekanan sistolik ventrikel kanan 109 mmHg dan ejeksi sistolik ventrikel kiri 67%. Teknik anestesi yang digunakan adalah anestesi epidural. Dilakukan pemasangan kateter vena sentral untuk memantau tekanan vena sentral. Regimen epidural yang digunakan adalah bupivacaine plain 0,3% dan fentanyl 50 mcg total volume 15 ml dengan teknik titrasi. Selama seksio sesarea, tekanan darah stabil, detak jantung dan saturasi oksigen baik. Pasien dipantau di ruang pemulihan selama 1 jam dan kemudian dipindahkan ke ICU dan dipulangkan pada hari ke 10 pasca operasi. Kesimpulan, pasien dengan ASD dan hipertensi pulmonal yang menjalani seksio sesarea dapat dilakukan anestesi epidural dengan teknik titrasi. Atrial Septal Defect with Severe Pulmonary Hypertension was Scheduled for Cesarean Section Abstract Congenital abnormalities of the heart and cardiovascular system occur in 7 to 10 per 1,000 of live births (0.7 - 1.0%). Congenital heart disease is the most common form of congenital diseases and amounted to approximately 30% of all incidents of congenital diseases. Congenital heart defects are most often neglected in childhood is secundum atrial septal defect (ASD). The risk for non-cardiac surgery would increase if found heart failure, pulmonary hypertension and cyanosis. A 33-years old primigravida, in labor at 32-34 weeks of gestation who underwent caesarean section under epidural anesthesia. On physical examination pulse was 100 x/min, blood pressure was 115/74 mmHg, oxygen saturation was 90-94% with oxygen supplement 10 L/min, bilateral pitting pedal edema was present. All the laboratory results within normal limits. 2D Echo results osteum secundum ASD (2-3 cm in diameter), bidirectional shunt dominan right to left shunt (Eisenmenger’s syndrome), Tricuspid Regurgitation, Severe Pulmonary Hypertension with an estimated right ventricle systolic pressure of 109 mmHg and left ventricle systolic ejection fraction of 67%. The anesthetic technique was epidural anesthesia. We performed central venous catheter to monitoring central venous pressure. The epidural regimens used were bupivacaine plain 0,3% and fentanyl 50 mcg total volume 15 ml with titration techniques. During cesarean section, patient was stable blood pressure, heart rate and oxygen saturation. Patient was monitored in recovery room for 1 hour and then transferred to ICU and discharged on 10th postoperative day. Conclusion, patients with ASD and severe pulmonary hipertention, we can perform epidural anesthesia with titration techniques.

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