妊娠晚期突发急性肺栓塞成功救治一例

Successful Treatment of Acute Pulmonary Embolism in the Third Trimester of Pregnancy:A Case Report

肺栓塞是由内源性或外源性栓子阻塞肺动脉或其分支后引起循环异常和心功能障碍的临床综合征。报道1例妊娠晚期急性肺栓塞并救治成功的病例。患者因“先兆早产”入院行保胎治疗,静脉血栓栓塞症评估未提示高风险,但患者于入院第4天用力排便后出现心慌、胸闷及呼吸困难。患者心率增快,血氧降低,血压正常,D-二聚体升高,余无明显异常。心电图提示ST段中度压低及T波异常。超声检查提示双下肢深静脉血流流速极缓慢,肺动脉高压轻度,右心室略增大,余未见明显异常。经多学科会诊讨论后,考虑为妊娠期急性肺栓塞,患者起病急、进展迅速,故急诊行子宫下段剖宫产术终止妊娠后转诊到综合医院重症监护病房治疗,转院后患者出现呼吸衰竭、机械通气不能维持氧合,予静脉-静脉体外膜肺氧合(veno-venous extracorporeal membrane oxygenation,V-V ECMO)治疗维持氧合,随后予取栓、溶栓等对症治疗,经积极救治,患者预后良好。通过本病例旨在提高临床医生对妊娠期肺栓塞疾病的认识及警觉性,对其危险因素应动态并个体化评估,做到早期发现、及时预防,从而挽救母婴生命,降低病死率。

Pulmonary embolism(PE) is a clinical syndrome in which the pulmonary artery or its branches are obstructed by endogenous or exogenous emboli,resulting in circulatory abnormalities and cardiac dysfunction.A case of acute pulmonary embolism in the third trimester of pregnancy was successfully treated.The patient was admitted to our hospital because of "threatened preterm labor".Venous thromboembolism assessment on admission did not indicate high risk.However,the patient developed palpitation,chest tightness and dyspnea after forced defecation on the fourth day of admission.The patient had the increased heart rate,decreased blood oxygen,normal blood pressure,and increased D-dimer,and no other obvious abnormalities.Electrocardiogram showed the moderate ST depression and abnormal T wave.Ultrasound examination showed a very slow flow rate of deep veins of both lower limbs,mild pulmonary hypertension,and slightly enlarged right ventricle.Other ultrasound examination showed no obvious abnormalities.After multidisciplinary consultation and discussion,the acute pulmonary embolism during pregnancy was considered.This disease was characterized by acute onset and rapid progress.Therefore,the patient after the emergency cesarean section of the lower uterine segment was transferred to the ICU of the general hospital for treatment.After the transfer,the patient had respiratory failure and mechanical ventilation could not maintain oxygenation.The patient was treated with veno-venous extracorporeal membrane oxygenation(V-V ECMO) to maintain oxygenation,and then received symptomatic treatment such as thrombectomy and thrombolysis.After active treatment,the patient had a good prognosis.The purpose of this case report is to improve the awareness and alertness of pulmonary embolism during pregnancy,and to remind clinicians that the risk factors should be dynamically and individually assessed,to achieve early detection and timely prevention,so as to save the lives of mothers and infants and reduce the fatality.