| Sub-title | |
| Authors | David P Galea MD Mark Formosa MD, FRCOG M P Brincat PhD, FRCOG Louis Buhagiar MD, FRCP A Samuel MD, Dspec MN (Milan) Goce Kunowski MD, Spec in Radiology |
| Abstract | A 28 year-old female in her second pregnancy, having had a previous normal full term pregnancy, presented at 34 weeks gestation with a 7-day history of shortness of breath, initially on exertion but on presentation also at rest. The patient had also been complaining of pleuritic chest pain radiating to her back. The patient was admitted to the A&E Department. Arterial blood gases confirmed arterial hypoxaemia and hypocapnia, and an ECG sustained the possibility of pulmonary thromboembolism. A diagnosis of pulmonary embolism was made. The patient was transferred to the Coronary Care Unit and fully heparinised (unfractionated heparin), maintaining her APTT between 80 - 100 sec. Doppler investigation of both lower limbs did not reveal any venous thrombosis. A pulmonary perfusion scan was carried out to confirm diagnosis and assess the severity of the pulmonary embolism. A low dose of tracer was used due to the pregnancy (37 mmol). There was almost absent tracer uptake in the left lung field, absent uptake in the right upper lobe, and absent uptake in the lateral basal segment of the right lower lobe. Extensive bilateral pulmonary embolism was confirmed. Because of the severity of the embolus, respiratory function was not considered adequate for a normal vaginal delivery and a plan was made for an elective caesarean section at 36 weeks. Since heparin would have to be stopped at least 6 hours prior to surgery, a temporary vena-cava filter was inserted. The interventional radiologist used a NitinolR temporary filter taking into consideration the age of the patient. The pulmonary-perfusion scan was repeated prior to the caesarean section and this showed a mild improvement, although generalised impairment was still present. Anticardiolipin antibody levels (IgG) were found to be five times the normal value. This was highly significant and a diagnosis of antiphospholipid antibody syndrome was made. At 36 weeks gestation an elective lower segment caesarean section was performed in a theatre with facilities for cardiopulmonary bypass at hand.The patient was again fully heparinised after the caesarean section (Heparin 6500 units/6 hours). Her general condition was stable, and the patient was transferred to the High Dependency Unit. The temporary filter was removed on 4th December 2001, the heparin was again stopped 6 hours before. During the procedure the extent of the inferior vena cava obstruction was assessed. Extensive thrombosis involving the whole of the lower part of the inferior vena cava prompted the decision to insert a permanent NitinolR vena cava filter. The patient was warfarinised from the next day and she was discharged a week later on Warfarin 8mg daily (INR 2-3). |
Published in: | |
| Journal | Malta Medical Journal |
| Volume | 16 Issue 02 |
| Pages | 36 - 38 |
| Date | 01/07/2004 |
| Link to journal | |
| Key words | anticardiolipin antibodies, pregnancy, pulmonary embolism |