CARDIAC PROBLEMS IN PREGNANCY

Transcription

1 CARDIAC PROBLEMS IN PREGNANCY LAS VEGAS, NEVADA, USA 27 February 1 March 2016

2 SUCCESSFUL TREATMENT WITH RECOMBINANT TISSUE PLASMINOGEN ACTIVATOR OF MASSIVE PULMONARY EMBOLISM IN THE 16 TH WEEK OF PREGNANCY Daniel B. Petrov, MD Maria H. Milanova. MD, PhD Adelina Peneva, MD Emergency Hospital Pirogov, Sofia, Bulgaria

3 BACKGROUND Thrombolytic agents have been used successfully to treat patients with massive pulmonary embolism, but experience with these drugs in pregnancy is limited.

4 OBJECTIVE The aim of this study is to present the case of massive pulmonary embolism in a pregnant woman with an excellent response to early thrombolytic therapy.

5 CASE PRESENTATION We report a 32-year-old pregnant female, who was at 16th week of gestation, presented with acute collapse and progressive dyspnea over a few days. No risk factors were present in the patient s clinical history.

6 CASE PRESENTATION On physical examination, she had tachypnoea with respiratory rate of 30 per minute, hypotension (blood pressure 80/40 mmhg) and tachycardia (133 beats per minute). Laboratory evaluation was remarkable for D-dimer 3254 (normal < 234) and cardiac troponin 0.34 ng/ml (normal < 0.06).

7 CASE PRESENTATION The electrocardiogram (ECG) was notable for sinus tachycardia with a rate of 133 per minute, right axis deviation (deep S wave in lead I), and T wave inversion in leads V1-V4 (Fig 1).

8 Case 2 Admission ECG showed sinus tachycardia, deep S wave in lead I and T wave inversion in leads V1 V4.

9 CASE PRESENTATION The clinical presentation was highly suggestive of an acute PE, and intravenous heparin was started immediately. Doppler studies of legs showed bilateral proximal deep venous thrombosis, making the diagnosis of PE likely.

10 CASE PRESENTATION The diagnosis was rapidly confirmed in the ED with two-dimensional-doppler echocardiography that demonstrated signs of right ventricular dysfunction (the right ventricle was enlarged, hypokinetic and severe tricuspid regurgitation was present) and pulmonary hypertension (systolic pulmonary-artery pressure of 67 mmhg) as well as direct visualization of large thrombus at the bifurcation of the main pulmonary artery (Fig 2).

11 Transthoracic echocardiography revealed a large saddle thrombus at the bifurcation of the main pulmonary artery.

12 CASE PRESENTATION Because of significant haemodynamic instability and no improvement after intravenous heparin, the patient was treated with recombinant tissue plasminogen activator 100 mg over 2 hours with subsequent heparin infusion for 48 hours, when LMWH (enoxaparin) was started.

13 CASE PRESENTATION The response to fibrinolytic therapy was excellent without haemorrhagic complications. Her respiratory status dramatically improved and the heart rate and blood pressure normalized. Serial ECGs demonstrated that the main QRS axis returned to normal with reduction of the S wave amplitude in lead I (Fig 3).

14 Case 2 The ECG after fibrinolysis showed reduction of the S wave in lead I and slowing down of the heart rate.

15 CASE PRESENTATION Repeated echocardiogram performed 24 hours later showed that right ventricular systolic pressure decreased to 36 mmhg and right ventricular function and dimension returned to normal limits. Ultrasound scan revealed no signs of placental or fetal bleeding.

16 CASE PRESENTATION On follow-up 6 weeks later, the patient s condition was good and echocardiogram documented normal right ventricular function. LMWH was continued until delivery, and a healthy child was born at term.

17 CONCLUSION Based on our case and on what has been previously described in the literature, early thrombolytic therapy should be considered as an option in the management of unstable pregnant patients with massive pulmonary embolism.

18 Acknowledgements This study was supported by the pharmaceutical company BOEHRINGER INGELHEIM.

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