586578 research-article2015

PRF0010.1177/0267659115586578PerfusionBataillard et al.

Case Report

Extracorporeal life support for massive pulmonary embolism during pregnancy

Perfusion 2016, Vol. 31(2) 169­–171 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0267659115586578 prf.sagepub.com

A Bataillard, A Hebrard, L Gaide-Chevronnay, M Casez, G Dessertaine, M Durand, O Chavanon and P Albaladejo

Abstract Massive pulmonary embolism is a leading cause of death during pregnancy. While the prevention of thromboembolic disease during the peripartum period is codified, there is no consensus regarding its treatment. We report two cases of pregnant women who had massive pulmonary embolisms (PE) and shock treated with veno-arterial extracorporeal life support (ECLS) and heparin therapy. Haemodynamic and oxygenation parameters were rapidly restored. The patients completely recovered and the pregnancies continued. The patients did not develop pulmonary hypertension. ECLS can be considered as a successful treatment option of massive pulmonary embolism during pregnancy. Keywords pulmonary embolism; pregnancy; extracorporeal life support; thrombolysis; vital distress

Introduction Pulmonary embolism (PE) during pregnancy is the main cause of maternal mortality in developed countries.1 Thrombolysis should be considered in massive PE during pregnancy even though it can induce bleeding. We describe two cases of massive PE occurring during pregnancy successfully treated by extracorporeal life support (ECLS) and continuous heparin therapy.

Case History Case 1 A 35-year-old woman, 27 weeks pregnant, was admitted to hospital with shortness of breath and chest pain. Her pregnancy was complicated by hypertension. She was overweight (body mass index: 50.7) and was bedridden for 3 days because of left leg pain. On admission, she had tachycardia, low blood pressure and the oxygen saturation in room air was 69%. The chest computer tomography (CT) scan showed a massive PE in the main pulmonary arteries. She was treated with unfractionated heparin (UFH) and was transferred to the intensive care unit (ICU). The transthoracic echocardiogram (TTE) showed a severe right ventricular dilation. The arterial blood gas values revealed severe hypoxia (PaO2: 5.33

KPa), hypocapnia (PaCO2: 3.6 KPa) and a normal pH (7.40). The patient had a sinus rhythm of 140 bpm and a blood pressure of 90/60 mmHg; she also previously suffered from gestational hypertension. Due to the haemodynamic and respiratory instability, it was decided to immediately implant an ECLS circuit. Cannulation was performed surgically in the operating room (OR) under sedation and spontaneous ventilation. The femoral artery and vein were cannulated with a 17 and a 23 Fr cannula (Medtronic, Vienna, Austria); an 8 Fr cannula was inserted in the femoral artery for antegrade perfusion of the distal leg. The ECLS circuit consisted of a centrifugal pump Rotaflow and a hollow-fiber membrane oxygenator (Quadrox), connected with polyvinyl chloride tubing coated with Grenoble University Hospital and University of Grenoble, Grenoble, France Corresponding author: Amélie Bataillard Grenoble University Hospital and University of Grenoble B.P. 217, 38043 Grenoble Cedex 09 France Grenoble 38043 France. Email: [email protected]

Downloaded from prf.sagepub.com at University of Exeter on June 4, 2016

170

Perfusion 31(2)

Bioline (Maquet, Jostra Medizintechnik AG, Hirrlingen, Germany). The circuit was primed with normal saline. The ECLS was started with an inspired fraction of oxygen (FiO2) of 45% and a gas flow of 4 l/min with a mechanical gas blender (Sechrist, Anaheim, CA, USA), at a flow rate of 5.3 l/min to maintain a mean arterial pressure of 60-70 mmHg. The UFH level was monitored twice daily to achieve an activated clotting time ratio around 2.5. The circuit was heated by the oxygenator heater unit HU 35 (Maquet Cardiopulmonary AG, Hirrlingen, Germany). Obstetric monitoring showed a normal foetal development. Multiple TTE were performed to assess right and left ventricle function. After 10 days, the right ventricular (RV) function was normalized and ECLS weaning was achieved by reducing the pump flow to 1.8 l/min. The ECLS cannulae were surgically removed. Discharge from the ICU ward was possible on day 15. The patient had a groin wound infection treated with surgery and antibiotics. At 31 weeks of gestation, a Caesarean section for spontaneous membrane rupture was performed under general anaesthesia after a brief stop of the UFH. The patient was discharged on day 13 after the delivery. Two months later, on chest CT scan, the thrombus size was reduced; it had disappeared 3 months later. The premature newborn was kept in ICU for 11 weeks.

Case 2 A 26-year-old patient at 10 weeks of gestation was admitted to hospital for a probable PE. She had a previous PE 6 years before and was overweight. She was treated with subcutaneous tinzaparin, but suffered a cardiac arrest (CA) during mobilization 2 days later. Resuscitation was started immediately. Cardiac activity resumed after 10 minutes. ECLS implantation was decided because of haemodynamic instability with a blood pressure of 70/40 mmHg. In the OR, she had a new CA and ECLS cannulation was performed surgically during external cardiac massage, with a similar ECLS circuit as the previous case. The ECLS was started at a flow rate of 4.5 l/min and a FiO2 of 50%. In the ICU, a protective lung ventilation strategy was established with 6 ml/kg of her predicted bodyweight, FiO2 50% and a positive end-expiratory pressure (PEEP) of 5 cmH2O. She was extubated 6 hours later. Foetal echocardiography showed cardiac activity. After 4 days, a TTE found a normal RV function and the ECLS was surgically removed. The patient left the ICU after 8 days. Post-operative complications were a thrombus of the right external iliac artery due to cannulation and an infected groin wound treated with antibiotics. She was discharged on day 18. At 3 months, the TTE showed no

pulmonary hypertension. At 37 weeks the patient gave birth to an eutrophic baby.

Discussion The treatment of massive PE during pregnancy is challenging, as only few therapeutic options are available. These two cases showed that ECLS may be a therapeutic option. ECLS used in the management of massive PE in an unstable patient was life-saving in 13/21 patients.2 In a recent systematic review,3 67 pregnant and postpartum women were found to be assisted by ECLS. The majority (49) were veno-venous ECLS in pregnant women with acute respiratory distress syndrome (ARDS). Indications for veno-arterial ECLS included ARDS with haemodynamic instability, peripartum cardiogenic shock and amniotic fluid embolism. Overall maternal and foetal survival with ECLS were 80% for venovenous ECLS and 70% for venoarterial ECLS. In comparison with UFH, thrombolysis accelerates the resolution of RV dysfunction,4 but does not reduce short-term mortality.5 The use of a thrombolytic therapy is recommended by the ACCP guidelines6 in patients with haemodynamic failure, but it has been scarcely studied during pregnancy. In a series of 13 pregnant women treated by thrombolysis because of severe PE,7 no maternal death, two foetal deaths and five preterm deliveries were observed. The bleeding risk induced by thrombolysis is significant during pregnancy and the postpartum period, as well as haemodynamic instability or subsequent foetal extraction practiced in an emergency. The risk of major bleeding following thrombolysis is more important in pregnant women (30.8%) than in the non-pregnant population (20%).7,8 Moreover, the teratogenic effects of fibrinolysis have not been clearly assessed. We conclude that the bleeding risk following fibrinolysis is important, especially during pregnancy, and can be associated with haemodynamic instability and a subsequent emergency foetal extraction. Furthermore, the teratogenic risk induced by fibrinolysis has not yet been clearly studied. Fibrinolysis is not effective in all patients. Approximately 92% of patients can be considered as responders to thrombolysis, based on the clinical and echocardiographic improvements within the first 36 hours following injection. Surgical pulmonary embolectomy is an effective treatment option for massive PE. Cardiac surgery during pregnancy has a high incidence of foetal mortality. Eight surgical embolectomies during pregnancy were reviewed with no maternal death, three foetal deaths and four preterm deliveries.7 In our case studies, it was decided to rapidly restore haemodynamic and oxygenation parameters in order to limit the bleeding and teratogenic risks.

Downloaded from prf.sagepub.com at University of Exeter on June 4, 2016

171

Bataillard et al.

The objective of oxygenation during ECLS was to avoid hyperoxia and its consequences on the foetus: the incidence of retinopathy of prematurity increases with exposure to unrestricted oxygen supply. Mother ventilation with a high FiO2 slightly increases foetal oxygenation, but causes a concomitant increase in oxygen free radical activity for the mother and baby.9

Conclusion The conventional treatment of severe PE during pregnancy is thrombolysis. However, ECLS can be used as an alternative technique in order to restore haemodynamic stability. Declaration of Conflicting Interest The authors declare that there is no conflict of interest.

Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

References 1. Bourjeily G, Paidas M, Khalil H, Rosene-Montella K, Rodger M. Pulmonary embolism in pregnancy. Lancet 2010; 375: 500–512.

2. Maggio P, Hemmila M, Haft J, Bartlett R. Extracorporeal life support for massive pulmonary embolism. J Trauma 2007; 62: 570–576. 3. Sharma NS, Wille KM, Bellot SC, Diaz-Guzman E. Modern use of extracorporeal life support in pregnancy and postpartum. ASAIO J 2015; 61: 110-114. 4. Konstantinides S, Tiede N, Geibel A, Olschewski M, Just H, Kasper W. Comparison of alteplase versus heparin for resolution of major pulmonary embolism. Am J Cardiol 1998; 82: 966–970. 5. Konstantinides S, Geibel A, Heusel G, Heinrich F, Kasper W. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med 2002; 347: 1143–1150. 6. Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133: 454S–545S. 7. te Raa GD, Ribbert LS, Snijder RJ, Biesma DH. Treatment options in massive pulmonary embolism during pregnancy; a case-report and review of literature. Thromb Res 2009; 124: 1–5. 8. Fiumara K, Kucher N, Fanikos J, Goldhaber SZ. Predictors of major hemorrhage following fibrinolysis for acute pulmonary embolism. Am J Cardiol 2006; 97: 127–129. 9. Khaw KS, Ngan Kee WD, Chu CY, et al. Effects of different inspired oxygen fractions on lipid peroxidation during general anaesthesia for elective Caesarean section. Br J Anaesth 2010; 105: 355–360.

Downloaded from prf.sagepub.com at University of Exeter on June 4, 2016