A 34-year-old Vietnamese woman presented with pulmonary thromboembolism following a cesarean delivery. She experienced cardiac arrest and was resuscitated, but later died from a pulmonary embolism. Pregnancy increases the risks of deep vein thrombosis and pulmonary embolism due to venous stasis, a hypercoagulable state, and vascular injury during delivery. Cesarean delivery further increases these risks compared to vaginal birth. While low molecular weight heparin can effectively prevent and treat thrombosis, early recognition and treatment are needed to reduce the high mortality rates associated with pulmonary embolism during pregnancy.

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4. • N. T. H. 34 year old. 2012. Housekeper. Bình Phước
• Time and date: 15g30’ - 15/09/2006
: Multipara, cephalic presentation / two previous
cesarean delivery
• The time of this Cesarean delivery: 9h20
• Anesthesia management: spinal anesthesia

5. Spinal anesthesia

6. 10h Cesarean delivery

7. • After close the myometrial, the pateint have cyanotic,
tachypnea, and decreased breathsounds
• Signs of right ventricular failure: an split second
heart sound, jugular venous distension
• ECG : right-axis shift, P pulmonale, ST-T segment
abnormalities, T-wave inversion, supraventricular
arrhythmias.
• Cardiac arret
• Make CPR and reanimation

8. 13h55’ Atony uterus: Hysterectomy after cesarean 4h 
Disorder of coagulation: platelet: 221000, TP: 16%, TCK:
70”, Fib 29mg%, RC (-)

9. Treatment disorder of coagulation

10. • ELISA D-Dimer : 530
1.Chest radiographs: an elevated hemidiaphragm,
and a peripheral segmental infiltrate
2.Spiral CT: thromboembolie of right segmental
pulmonary arteries
3.Echocardiographic: dilation of right ventricular

12. INCIDENT
− Pulmonary thromboembolism (PTE) occurs in
approximately 0.01%--0.05% of all pregnancies.1,2
− The most common etiology is deep vein
thrombosis (DVT).
− Deep vein thrombosis occurs in 0.02% to 0.36% of
pregnancies.3
1.Weiner CP. Clin Obstet Gynecol 1985; 28:107-18.
2.Gherman RB, Goodwin TM, Leung B, et al. Obstet Gynecol 1999; 94:730-4
3.Rothbard MJ ,Gluck D, Stone ML .NY State Jmed 1976;76:582-4.
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16. ETIOLOGY
− Pregnancy: twofold - fivefold increase in the relative
risk of thromboembolism.4,5
− Result of at least three factors:
1.An increase in venous stasis
2.The hypercoagulable state of pregnancy
3.The vascular injury associated with vaginal or
cesarean delivery
4.Stein PD, Hull RD, Kayali F, et al. Am J Med 2004; 117:121-5.
5.Heit J, Kobberveg C, Petterson T, et al. Ann Intern Med 2005; 143:697-706.
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17. VENOUS STASIS
− Maternal blood volume and cardiac output
increase approximately 50% during pregnancy.6
− The gravid uterus compresses the inferior vena
cava as well as other anatomic structures .
− Vena caval compression results in venous stasis
distal to the compression in the pelvis and lower
extremities
6.Palmer SK, Zamudio S, Coffin C, et al.. Obstet Gynecol 1992; 80:1000-6.
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18. CHANGES IN COAGULATION
• Pregnancy:enhanced platelet turnover, coagulation,
and fibrinolysis.
• Increase clotting factors: fibrinogen, V, VII, VIII, IX, X,
and XII.
• Parturition accelerates platelet activation, coagulation,
and fibrinolysis.7,8
.7.Gerbasi FR, Bottoms S, Farag A, et al. Obstet Gynecol 1990; 75:385-9.
8.Gerbasi FR, Bottoms S, Farag A, et al.. Am J Obstet Gynecol 1990; 162:1158-63
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19. VASCULAR DAMAGE
− Both vaginal delivery and separation of the placenta
result in vascular trauma, leading to an
acceleration of coagulation activity.
− Cesarean delivery increase the risk of
thromboembolism.
− DVT and PTE are as much as eight times higher
after cesarean delivery than after vaginal. 9,10
.
9.Ros HR, Lichtenstein P, Bellocco R, et al. Am J Obstet Gynecol 2002; 186:198-203.
10. Lindqvist P, Dahlback B, Marsal K. . Am Coll Obstet Gynecol 1999; 94:595-9.
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20. OBSTETRIC CONDITIONS
− Higher risk of PTE in women preeclampsia and
multiple gestation (increased relative risks of
sevenfold to eightfold, and twofold to threefold,
respectively). 11,12,13
− These obstetric conditions or their management are
associated with risk factors for thromboembolic
disease
11.Ros HR, Lichtenstein P, Bellocco R, et al. Am J Obstet Gynecol 2002; 186:198-203.
12.Lindqvist P, Dahlback B, Marsal K.. Am Coll Obstet Gynecol 1999; 94:595-9.
13.James AH, Tapson VF, Goldhaber SZ. . Am J Obstet Gynecol 2005; 193:216-9.
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21. COINCIDENTAL DISEASE
− A history of previous thromboembolism increases
the risk of PTE during pregnancy 13
− Heart disease (odds ratio [OR], 7.1), smoking (OR,
1.7), obesity (OR,4.4), antiphospholipid antibody
syndrome (OR, 15.0), thrombophilias (OR, 25.0
to 50.0).14,15,16
13. Bremme K, Lind H, Blomback M. . Obstet Gynecol 1993; 78:78-83
14.Lindqvist P, Dahlback B, Marsal K. . Am Coll Obstet Gynecol 1999; 94:595-9.
15. Sipes SL, Weiner CP. Semin Perinatol 1990; 14:103-18.
16.Bonnar J. Clin Obstet Gynecol 1981; 8:455-73
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22. PATHOPHYSIOLOGY
The manifestations and prognosis of PTE depend on
1.The size and number of emboli
2.Concurrent cardiopulmonary function,
3.The rate of clot fragmentation and lysis,
4.The presence or absence of a source for recurrent
emboli
5.The location of the embolism17,18
17.Stein PD, Beemath A, Matta F, et al. :. Am J Med 2007; 120:871-9.
18..Spence TH.. In Civetta JM, Taylor RM, Kirby RR, Philadelphia, JB Lippincott, 1988:1091-2
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23. TREATMENT
Approximately 10% of all patients with a
pulmonary embolus die within the first hour. 19
Therapy focuses on providing:
1. Dequate maternal and fetal oxygenation
2. Support of maternal circulation, including
uteroplacental perfusion
3. Immediate anticoagulation or venous
interruption to prevent recurrence of a
pulmonary embolus.20
19.Dalen JE, Alpert JS. Cardiovasc Dis 1975; 17:259-70
20.Spence TH. In Civetta JM, Taylor RM, Kirby RR, editors. Critical Care. Philadelphia, JB Lippincott, 1988:1091-2.
.
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24. TREATMENT
− DEEP VEIN THROMBOSIS
− LMWH for both prophylactic and therapeutic
anticoagulation during pregnancy has become
common place.21
− LMWH has greater antithrombotic activity (anti-factor
Xa) than anticoagulant activity (anti-factor
IIa), it does not affect the aPTT.
.
21.American College of Obstetricians and Gynecologists Committee on Practice.. ACOG Practice Bulletin No. 19. Washington, DC,
August 2000.
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25. TREATMENT
 Enoxaparin (Lovenox), injected once or twice daily at a
dose of 40mg(1mg=100U), for thromboprophylaxis
during pregnancy.22
 Peak anti-factor Xa activity occurs within 3 to 5 hours of
administration, and 50% of the total antifactor Xa activity
disappears within 6 hours.23
 Both the efficacy and the maternal and fetal safety of
LMWH have been established.
22.Eisenach JC. . American Society of Regional Anesthesia. ASRA News 1995;Nov:5-6.
23.American College of Obstetricians and Gynecologists Committee on Practice.. ACOG Practice Bulletin No. 19. Washington, DC,
August 2000.
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26. CONCLUSION
Appropriate treatment of DVT reduces the
incidence of PTE to 0.7% to 4.5%, 24,25 and it
reduces the mortality rate to 0.7%.25,26
Anesthesia providers are often involved in the
resuscitation of patients with embolic disorders
Early recognition, diagnosis, and treatment are
necessary to reduce associated morbidity and
mortality.
24. Rothbard MJ, Gluck D, Stone ML. . N Y State J Med 1976; 76:582-4
25.Villasanta U.. Am J Obstet Gynecol 1965; 93:142-60.
26. Sipes SL, Weiner CP. Semin Perinatol 1990; 14:103-18.
.
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27. VIET NAM VIET NAM
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28. THANK YOU!
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NGUYỄN THỊ HỒNG VÂN
VIET NAM
Email: bshongvan_2013@yahoo.com