Journal of Obstetrics and Gynaecology
ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: http://www.tandfonline.com/loi/ijog20
Pulmonary embolism presenting as a seizure in the immediate postpartum period Y. H. Ching, E. N. Alvey, H. R. Omar, C. M. Lynch, D. Mangar & E. M. Camporesi To cite this article: Y. H. Ching, E. N. Alvey, H. R. Omar, C. M. Lynch, D. Mangar & E. M. Camporesi (2015) Pulmonary embolism presenting as a seizure in the immediate postpartum period, Journal of Obstetrics and Gynaecology, 35:1, 92-93, DOI: 10.3109/01443615.2014.936842 To link to this article: http://dx.doi.org/10.3109/01443615.2014.936842
Published online: 14 Jul 2014.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijog20 Download by: [Universite Laval]
Date: 05 November 2015, At: 16:42
92
Obstetrics Case Reports
published literature suggest that for young women of childbearing age who require AVR, the Ross procedure should be recognised as a safe operation with low operative mortality and favourable long-term results, which are unaffected by pregnancy and with only minimal adverse effects on maternal and fetal outcome. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Journal of Obstetrics and Gynaecology 2015.35:92-93.
References Ali U, Copel J, Friedman A. 2009. A successful pregnancy outcome following the Ross procedure: a case report. American Journal of Perinatology 26:287–289. Dore A, Somerville J. 1997. Pregnancy in patients with pulmonary autograft valve replacement. European Heart Journal 18:1659–1662. El-Hamamsy I, Eryigit Z, Stevens LM et al. 2010. Long-term outcomes after autograft versus homograft aortic root replacement in adults with aortic valve disease: a randomised controlled trial. Lancet 376:524–531. Heuvelman HJ, Arabkhani B, Cornette JM et al. 2013. Pregnancy outcomes in women with aortic valve substitutes. American Journal of Cardiology 111:382–387. Larson EW, Edwards WD. 1984. Risk factors for aortic dissection: a necropsy study of 161 cases. American Journal of Cardiology 53:849–855. Lee CN, Wu CC, Lin PY et al. 1994. Pregnancy following cardiac prosthetic valve replacement. Obstetrics and Gynecology 83:353–356. Losenno KL, Goodman RL, Chu MW. 2012. Bicuspid aortic valve disease and ascending aortic aneurysms: gaps in knowledge. Cardiology Research and Practice 2012:145202. Martin TC, Idahosa V, Ogunbiyi A et al. 2003. Successful pregnancy and delivery after pulmonary autograft operation (Ross procedure) for rheumatic aortic valve insufficiency. West Indian Medical Journal 52:62–64. Ross DN. 1967. Replacement of aortic and mitral valves with a pulmonary autograft. Lancet 2:956–958. Vitale N, De Feo M, De Santo LS et al. 1999. Dose-dependent fetal complications of warfarin in pregnant women with mechanical heart valves. Journal of the American College of Cardiology 33:1637–1641.
Pulmonary embolism presenting as a seizure in the immediate postpartum period Y. H. Ching1, E. N. Alvey1, H. R. Omar2, C. M. Lynch3, D. Mangar1,4 & E. M. Camporesi1,4 1Department of Research, Florida Gulf-to-Bay Anesthesiology
Associates, 3Department of Obstetrics and Gynecology and 4Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, 2Department of Internal Medicine, Mercy Medical Center, Clinton, IA, USA DOI: 10.3109/01443615.2014.936842 Correspondence: Y.-H. Ching, 1 Tampa General Circle, Suite C-208, Tampa, FL 33606, USA. E-mail: [email protected]
Introduction Seizures in the postpartum period are not always due to eclampsia, and the various potential aetiologies have a considerable amount of overlap leading to difficulty in diagnosis. Massive pulmonary embolism (PE) as a cause of seizure in the postpartum period has not been previously reported. Herein, we describe a case of massive PE presenting with seizures in the immediate postpartum period, diagnosed utilising bedside transthoracic echocardiography (TTE) and successfully treated by surgical embolectomy.
Case report A 33-year-old, G3P2002, African-American woman presented for scheduled induction of labour at 39 weeks’ gestation, with a pregnancy complicated by malnutrition and anaemia. Her history was significant for gastric bypass surgery, from which the patient achieved a normal
body mass index prior to pregnancy. She did not have a current or remote history of tobacco use, pre-eclampsia, eclampsia, epilepsy or a family history of seizure disorder. Approximately 2 h after a spontaneous vaginal delivery, the patient experienced a postpartum haemorrhage, which was controlled by misoprostol and oxytocin. An hour later, she suddenly became unresponsive with development of myoclonic seizure activity. The patient was started on diazepam and fluid resuscitation, but she continued to deteriorate and went into pulseless electrical activity (PEA), for which cardiopulmonary resuscitation (CPR) measures were initiated. She was stabilised and prepared for transfer to the intensive care unit (ICU), but she again arrested with PEA approximately 5 min later, followed by CPR with return of spontaneous circulation (ROSC). During transport to the ICU, the patient arrested for a third time with PEA, and CPR was resumed until ROSC was achieved. Bedside TTE was performed revealing dilation of the right atrium (RA) and right ventricle (RV); severe tricuspid regurgitation (TR) and pulmonary hypertension; right ventricular dysfunction and an echodense lesion in the pulmonary artery, suggestive of acute saddle PE (Figure 1). As she had undergone a recent vaginal delivery and had experienced chest compressions, thrombolytic therapy was contraindicated. As such, she was brought to the operating room and underwent successful surgical pulmonary embolectomy with extraction of a large saddle embolus and placement of an IVC filter. A Bakri balloon for control of active uterine bleeding was also performed. The patient was started on levetiracetam to control post-hypoxic myoclonus activity (Lance-Adams syndrome) and head magnetic resonance imaging did not demonstrate any abnormalities. Anticoagulation therapy with warfarin was initiated on postoperative day (POD) 8 and was continued upon discharge. The remainder of the patient’s hospital course was uneventful, and she was discharged home on POD 22. The patient returned for her postpartum examination and was well except for some memory deficits.
Discussion Venous thromboembolism (VTE), a disease state inclusive of deep vein thrombosis (DVT) and PE, remains a leading cause of maternal morbidity and mortality in developed countries (Berg et al. 2010; Chang et al. 2003; Heit et al. 2005). Pregnant and postpartum women are at a four- to five-fold increased risk of developing VTE compared with non-pregnant women, with the highest incidence in the first week after delivery (Conti et al. 2013; Heit et al. 2005; James 2009; Baue 1986; Virkus et al. 2011). As such, prompt recognition and treatment of acute PE in this setting is paramount. However, the clinical presentation of acute PE can mimic the changes of normal pregnancy and various pathophysiological states, leading to potential delays in diagnosis and treatment. Acute PE can also present in unusual ways, such as seizures, which occur in less than 1% of cases (Meyer 2009). Although the pathophysiology of seizures in PE is not well-defined, Marine and Goldhaber (1997) theorised that seizures may arise from transient cerebral ischaemia, hypoxia and metabolic and respiratory acidosis resulting from the right ventricular and respiratory failure caused by the pulmonary embolus. The presented case emphasises several interesting aspects of acute PE in pregnancy and the postpartum period. In reviewing the literature, we did not find any previously reported cases of acute PE presenting as seizures in this population. However, the literature supports maintaining a high index of suspicion for PE in any patient presenting with seizures and abnormal vital signs that are not explained by the seizure activity alone (Volz and Jasani 2014). As our patient was haemodynamically unstable and did not have a history of seizures, PE was felt to be high in the differential. Our case also demonstrates the potential role of echocardiography in the diagnosis of PE in pregnancy. Current standards for imaging the pulmonary arteries presents risks for radiation and contrast agent exposure to mother and fetus. Echocardiography mitigates these risks while also providing the ability for expeditious evaluation. Additionally, while thrombolysis is currently recommended for the initial treatment of massive PE, recent evidence suggests that early surgical embolectomy may impart a greater survival benefit (Basciani et al. 2011). In summary, clinicians treating pregnant and parturient women
Journal of Obstetrics and Gynaecology 2015.35:92-93.
Obstetrics Case Reports 93
Figure 1. Bedside transthoracic echocardiogram demonstrating findings consistent with acute massive pulmonary embolus. (a) Parasternal long axis right ventricular inflow view showing severe tricuspid regurgitation. (b) Continuous wave Doppler can used to measure the pressure gradient across the tricuspid valve, which is used to indirectly estimate the pulmonary artery systolic pressure. This patient’s right ventricular systolic pressure is 60 mmHg plus the estimated right atrial pressure. (c) Parasternal short axis pulmonary artery view showing an echodense structure in the pulmonary artery bifurcation suggestive of saddle embolus.
should maintain a high level of suspicion for PE, especially in the setting of unexplained new-onset seizures. Consideration should be given for the use of bedside echocardiography in diagnosing PE in pregnancy, as well as surgical embolectomy as a possible first-line treatment for patients with acute submassive or massive PE, though further study is warranted.
Virkus RA, Løkkegaard EC, Lidegaard Ø et al. 2011. Venous thromboembolism in pregnant and puerperal women in Denmark 1995–2005: A national cohort study. Thrombosis and Haemostasis 106:304–309. Volz EE, Jasani N. 2014. Seizure as a presentation of pulmonary embolism. Journal of Emergency Medicine 46:e1–e4.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
A decision dilemma: Cushing syndrome during pregnancy M. Darocas1, N. Ruiz1, M. T. Bergoglio2 & A. Cano1,3
References Basciani R, Eberle B, Schmidli J et al. 2011. Pulmonary embolectomy: recommendation for early surgical intervention. Journal of Cardiac Surgery 26:560–561. Baue AE. 1986. Prevention of venous thrombosis and pulmonary embolism. NIH Consensus Development. Journal of the American Medical Association 256:744–749. Berg CJ, Callaghan WM, Syverson C et al. 2010. Pregnancy-related mortality in the United States, 1998 to 2005. Obstetrics and Gynecology 116:1302–1309. Chang J, Elam-Evans LD, Berg CJ et al. 2003. Pregnancy-related mortality surveillance –United States, 1991–1999. MMWR Surveillance Summaries 52:1–8. Conti E, Zezza L, Ralli E et al. 2013. Pulmonary embolism in pregnancy. Journal of Thrombosis and Thrombolysis 37:251–270. Heit JA, Kobbervig CE, James AH et al. 2005. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year populationbased study. Annals of Internal Medicine 143:697–706. James AH; American Society of Hematology Education Program. 2009. Pregnancy-associated thrombosis. Hematology 2009:277–285. Marine JE, Goldhaber SZ. 1997. Pulmonary embolism presenting as seizures. Chest 112:840–842. Meyer MA. 2009. Seizure as the presenting sign for massive pulmonary embolism: Case report and review of the literature. Seizure 18:76–78.
1Obstetrics and Gynaecology Service, 2Endocrinology Unit, University Hospital Dr Peset and 3Department of Paediatrics, Obstetrics and Gynaecology, University of Valencia, Valencia, Spain
DOI: 10.3109/01443615.2014.937329 Correspondence: A. Cano, Department of Pediatrics, Obstetrics and Gynecology, Facultad de Medicina, Av Blasco Ibáñez 15, 46010 Valencia, Spain. E-mail: [email protected]
Introduction The rare presentation of Cushing syndrome during pregnancy prevents the use of established guidelines for management. A three-step dilemma challenges clinicians making this diagnosis: surveillance, medical or surgical treatment in the case of intervention, or open surgery or laparoscopy in the case of surgery. A critical analysis of each option is presented here, based on the clinical case of a woman who was diagnosed with Cushing syndrome during pregnancy and who underwent laparoscopic excision of a functional adrenal adenoma. Cushing syndrome is rare during pregnancy because frequent anovulation adds to an already uncommon process (5–25 cases per million/
ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: http://www.tandfonline.com/loi/ijog20
Pulmonary embolism presenting as a seizure in the immediate postpartum period Y. H. Ching, E. N. Alvey, H. R. Omar, C. M. Lynch, D. Mangar & E. M. Camporesi To cite this article: Y. H. Ching, E. N. Alvey, H. R. Omar, C. M. Lynch, D. Mangar & E. M. Camporesi (2015) Pulmonary embolism presenting as a seizure in the immediate postpartum period, Journal of Obstetrics and Gynaecology, 35:1, 92-93, DOI: 10.3109/01443615.2014.936842 To link to this article: http://dx.doi.org/10.3109/01443615.2014.936842
Published online: 14 Jul 2014.
Submit your article to this journal
Article views: 32
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijog20 Download by: [Universite Laval]
Date: 05 November 2015, At: 16:42
92
Obstetrics Case Reports
published literature suggest that for young women of childbearing age who require AVR, the Ross procedure should be recognised as a safe operation with low operative mortality and favourable long-term results, which are unaffected by pregnancy and with only minimal adverse effects on maternal and fetal outcome. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Journal of Obstetrics and Gynaecology 2015.35:92-93.
References Ali U, Copel J, Friedman A. 2009. A successful pregnancy outcome following the Ross procedure: a case report. American Journal of Perinatology 26:287–289. Dore A, Somerville J. 1997. Pregnancy in patients with pulmonary autograft valve replacement. European Heart Journal 18:1659–1662. El-Hamamsy I, Eryigit Z, Stevens LM et al. 2010. Long-term outcomes after autograft versus homograft aortic root replacement in adults with aortic valve disease: a randomised controlled trial. Lancet 376:524–531. Heuvelman HJ, Arabkhani B, Cornette JM et al. 2013. Pregnancy outcomes in women with aortic valve substitutes. American Journal of Cardiology 111:382–387. Larson EW, Edwards WD. 1984. Risk factors for aortic dissection: a necropsy study of 161 cases. American Journal of Cardiology 53:849–855. Lee CN, Wu CC, Lin PY et al. 1994. Pregnancy following cardiac prosthetic valve replacement. Obstetrics and Gynecology 83:353–356. Losenno KL, Goodman RL, Chu MW. 2012. Bicuspid aortic valve disease and ascending aortic aneurysms: gaps in knowledge. Cardiology Research and Practice 2012:145202. Martin TC, Idahosa V, Ogunbiyi A et al. 2003. Successful pregnancy and delivery after pulmonary autograft operation (Ross procedure) for rheumatic aortic valve insufficiency. West Indian Medical Journal 52:62–64. Ross DN. 1967. Replacement of aortic and mitral valves with a pulmonary autograft. Lancet 2:956–958. Vitale N, De Feo M, De Santo LS et al. 1999. Dose-dependent fetal complications of warfarin in pregnant women with mechanical heart valves. Journal of the American College of Cardiology 33:1637–1641.
Pulmonary embolism presenting as a seizure in the immediate postpartum period Y. H. Ching1, E. N. Alvey1, H. R. Omar2, C. M. Lynch3, D. Mangar1,4 & E. M. Camporesi1,4 1Department of Research, Florida Gulf-to-Bay Anesthesiology
Associates, 3Department of Obstetrics and Gynecology and 4Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, 2Department of Internal Medicine, Mercy Medical Center, Clinton, IA, USA DOI: 10.3109/01443615.2014.936842 Correspondence: Y.-H. Ching, 1 Tampa General Circle, Suite C-208, Tampa, FL 33606, USA. E-mail: [email protected]
Introduction Seizures in the postpartum period are not always due to eclampsia, and the various potential aetiologies have a considerable amount of overlap leading to difficulty in diagnosis. Massive pulmonary embolism (PE) as a cause of seizure in the postpartum period has not been previously reported. Herein, we describe a case of massive PE presenting with seizures in the immediate postpartum period, diagnosed utilising bedside transthoracic echocardiography (TTE) and successfully treated by surgical embolectomy.
Case report A 33-year-old, G3P2002, African-American woman presented for scheduled induction of labour at 39 weeks’ gestation, with a pregnancy complicated by malnutrition and anaemia. Her history was significant for gastric bypass surgery, from which the patient achieved a normal
body mass index prior to pregnancy. She did not have a current or remote history of tobacco use, pre-eclampsia, eclampsia, epilepsy or a family history of seizure disorder. Approximately 2 h after a spontaneous vaginal delivery, the patient experienced a postpartum haemorrhage, which was controlled by misoprostol and oxytocin. An hour later, she suddenly became unresponsive with development of myoclonic seizure activity. The patient was started on diazepam and fluid resuscitation, but she continued to deteriorate and went into pulseless electrical activity (PEA), for which cardiopulmonary resuscitation (CPR) measures were initiated. She was stabilised and prepared for transfer to the intensive care unit (ICU), but she again arrested with PEA approximately 5 min later, followed by CPR with return of spontaneous circulation (ROSC). During transport to the ICU, the patient arrested for a third time with PEA, and CPR was resumed until ROSC was achieved. Bedside TTE was performed revealing dilation of the right atrium (RA) and right ventricle (RV); severe tricuspid regurgitation (TR) and pulmonary hypertension; right ventricular dysfunction and an echodense lesion in the pulmonary artery, suggestive of acute saddle PE (Figure 1). As she had undergone a recent vaginal delivery and had experienced chest compressions, thrombolytic therapy was contraindicated. As such, she was brought to the operating room and underwent successful surgical pulmonary embolectomy with extraction of a large saddle embolus and placement of an IVC filter. A Bakri balloon for control of active uterine bleeding was also performed. The patient was started on levetiracetam to control post-hypoxic myoclonus activity (Lance-Adams syndrome) and head magnetic resonance imaging did not demonstrate any abnormalities. Anticoagulation therapy with warfarin was initiated on postoperative day (POD) 8 and was continued upon discharge. The remainder of the patient’s hospital course was uneventful, and she was discharged home on POD 22. The patient returned for her postpartum examination and was well except for some memory deficits.
Discussion Venous thromboembolism (VTE), a disease state inclusive of deep vein thrombosis (DVT) and PE, remains a leading cause of maternal morbidity and mortality in developed countries (Berg et al. 2010; Chang et al. 2003; Heit et al. 2005). Pregnant and postpartum women are at a four- to five-fold increased risk of developing VTE compared with non-pregnant women, with the highest incidence in the first week after delivery (Conti et al. 2013; Heit et al. 2005; James 2009; Baue 1986; Virkus et al. 2011). As such, prompt recognition and treatment of acute PE in this setting is paramount. However, the clinical presentation of acute PE can mimic the changes of normal pregnancy and various pathophysiological states, leading to potential delays in diagnosis and treatment. Acute PE can also present in unusual ways, such as seizures, which occur in less than 1% of cases (Meyer 2009). Although the pathophysiology of seizures in PE is not well-defined, Marine and Goldhaber (1997) theorised that seizures may arise from transient cerebral ischaemia, hypoxia and metabolic and respiratory acidosis resulting from the right ventricular and respiratory failure caused by the pulmonary embolus. The presented case emphasises several interesting aspects of acute PE in pregnancy and the postpartum period. In reviewing the literature, we did not find any previously reported cases of acute PE presenting as seizures in this population. However, the literature supports maintaining a high index of suspicion for PE in any patient presenting with seizures and abnormal vital signs that are not explained by the seizure activity alone (Volz and Jasani 2014). As our patient was haemodynamically unstable and did not have a history of seizures, PE was felt to be high in the differential. Our case also demonstrates the potential role of echocardiography in the diagnosis of PE in pregnancy. Current standards for imaging the pulmonary arteries presents risks for radiation and contrast agent exposure to mother and fetus. Echocardiography mitigates these risks while also providing the ability for expeditious evaluation. Additionally, while thrombolysis is currently recommended for the initial treatment of massive PE, recent evidence suggests that early surgical embolectomy may impart a greater survival benefit (Basciani et al. 2011). In summary, clinicians treating pregnant and parturient women
Journal of Obstetrics and Gynaecology 2015.35:92-93.
Obstetrics Case Reports 93
Figure 1. Bedside transthoracic echocardiogram demonstrating findings consistent with acute massive pulmonary embolus. (a) Parasternal long axis right ventricular inflow view showing severe tricuspid regurgitation. (b) Continuous wave Doppler can used to measure the pressure gradient across the tricuspid valve, which is used to indirectly estimate the pulmonary artery systolic pressure. This patient’s right ventricular systolic pressure is 60 mmHg plus the estimated right atrial pressure. (c) Parasternal short axis pulmonary artery view showing an echodense structure in the pulmonary artery bifurcation suggestive of saddle embolus.
should maintain a high level of suspicion for PE, especially in the setting of unexplained new-onset seizures. Consideration should be given for the use of bedside echocardiography in diagnosing PE in pregnancy, as well as surgical embolectomy as a possible first-line treatment for patients with acute submassive or massive PE, though further study is warranted.
Virkus RA, Løkkegaard EC, Lidegaard Ø et al. 2011. Venous thromboembolism in pregnant and puerperal women in Denmark 1995–2005: A national cohort study. Thrombosis and Haemostasis 106:304–309. Volz EE, Jasani N. 2014. Seizure as a presentation of pulmonary embolism. Journal of Emergency Medicine 46:e1–e4.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
A decision dilemma: Cushing syndrome during pregnancy M. Darocas1, N. Ruiz1, M. T. Bergoglio2 & A. Cano1,3
References Basciani R, Eberle B, Schmidli J et al. 2011. Pulmonary embolectomy: recommendation for early surgical intervention. Journal of Cardiac Surgery 26:560–561. Baue AE. 1986. Prevention of venous thrombosis and pulmonary embolism. NIH Consensus Development. Journal of the American Medical Association 256:744–749. Berg CJ, Callaghan WM, Syverson C et al. 2010. Pregnancy-related mortality in the United States, 1998 to 2005. Obstetrics and Gynecology 116:1302–1309. Chang J, Elam-Evans LD, Berg CJ et al. 2003. Pregnancy-related mortality surveillance –United States, 1991–1999. MMWR Surveillance Summaries 52:1–8. Conti E, Zezza L, Ralli E et al. 2013. Pulmonary embolism in pregnancy. Journal of Thrombosis and Thrombolysis 37:251–270. Heit JA, Kobbervig CE, James AH et al. 2005. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year populationbased study. Annals of Internal Medicine 143:697–706. James AH; American Society of Hematology Education Program. 2009. Pregnancy-associated thrombosis. Hematology 2009:277–285. Marine JE, Goldhaber SZ. 1997. Pulmonary embolism presenting as seizures. Chest 112:840–842. Meyer MA. 2009. Seizure as the presenting sign for massive pulmonary embolism: Case report and review of the literature. Seizure 18:76–78.
1Obstetrics and Gynaecology Service, 2Endocrinology Unit, University Hospital Dr Peset and 3Department of Paediatrics, Obstetrics and Gynaecology, University of Valencia, Valencia, Spain
DOI: 10.3109/01443615.2014.937329 Correspondence: A. Cano, Department of Pediatrics, Obstetrics and Gynecology, Facultad de Medicina, Av Blasco Ibáñez 15, 46010 Valencia, Spain. E-mail: [email protected]
Introduction The rare presentation of Cushing syndrome during pregnancy prevents the use of established guidelines for management. A three-step dilemma challenges clinicians making this diagnosis: surveillance, medical or surgical treatment in the case of intervention, or open surgery or laparoscopy in the case of surgery. A critical analysis of each option is presented here, based on the clinical case of a woman who was diagnosed with Cushing syndrome during pregnancy and who underwent laparoscopic excision of a functional adrenal adenoma. Cushing syndrome is rare during pregnancy because frequent anovulation adds to an already uncommon process (5–25 cases per million/
