This is the 3542nd article of Da Medical Care
Just three days ago a healthy baby was born, and the family was overjoyed. Early in the morning, Xiao Zhang also got up to pick up and pick up himself, after giving birth, he felt weak, and he did not get out of bed for more activities, and today he was ready to be discharged from the hospital, combing and combing his hair, and dressing up.
Just went to the bathroom, was combing his hair in front of the mirror, Xiao Zhang suddenly felt chest tightness, chest pain, and involuntarily fell to the ground. The patients on the side heard the strange noise and rushed over, and saw that while calling out to the nurse, they helped to help Xiao Zhang to the bed. The doctors and nurses rushed into the ward at the first time, taking oxygen for Xiao Zhang, who was lying on the bed, while measuring blood pressure. The monitor also quickly moved in, and when the finger pulse oxygen was connected, the oxygen saturation was less than 90%. The doctor on duty sensed the seriousness of the condition and immediately called the ICU doctor for consultation.
Dr. Sheng of the ICU arrived with a portable ultrasound with him. As we said before, ultrasound is a sharp weapon in the hands of ICU doctors, if it is not too big, I would like to carry it in my pocket every day like a stethoscope. While comforting the mother, Dr. Sheng took out the stethoscope for lung auscultation, and the breathing sound was good, there was no problem. In addition to the faster heartbeat on the monitor, the blood pressure is also normal. The party ultrasound came on, dr. Sheng Ma Li took out the cardiac ultrasound probe, and immediately gave Xiao Zhang a cardiac ultrasound examination at the bedside. The left heart is normal and pulsating vigorously; the right heart is large, and the two ventricles are almost the same width. Seeing this, Dr. Sheng counted in his heart, and then changed a high-frequency ultrasound probe to examine the blood vessels of the mother's lower limbs, and found a long blood clot in the femoral vein of the right lower limb. The mystery was revealed, and the culprit that caused Xiao Zhang's sudden chest tightness was acute pulmonary embolism!
Xiao Zhang felt very confused, my body has been very good, how can I get pulmonary embolism? There are many kinds of embolus that can block pulmonary arteries, such as fat, cancer embolism, air, amniotic fluid, etc., but the most common is pulmonary thromboembolism. It is a blood clot of lower limb or pelvic vein origin, which follows the blood flow through the right atrium and right ventricle into the pulmonary artery, blocking the branches of the relatively large pulmonary artery, hindering the flow of lung blood, and then affecting the patient's respiratory and circulatory function. Acute pulmonary embolism is the third most common cause of cardiovascular disease death worldwide, after coronary heart disease and stroke. Acute pulmonary embolism is an important cause of maternal mortality, with an incidence of up to 1 in 6400 during pregnancy and a 15-fold increase in postpartum than before delivery.
During pregnancy, due to the enlargement of the uterus and the compression of the abdominal veins, resulting in obstruction of blood return, varicose veins in the lower limbs and pelvis; during pregnancy, due to the action of progesterone, the blood is hypercoagulated, and it is easy to form venous thrombosis in the lower limbs and pelvis; coupled with postpartum bed rest, the risk of deep vein thrombosis and acute pulmonary embolism is increased.
"Do you want to draw blood to check the D-dimer?" Xiao Liu, an intern doctor on the side, asked. There are many factors that cause elevated D-dimer in hospitalized patients, such as pregnancy itself can be accompanied by an increase in this indicator, and D-dimer cannot diagnose pulmonary embolism. The gold standard for diagnosing acute pulmonary embolism is enhanced CT pulmonary angiography, and ultrasound can also help diagnose pulmonary embolism. Patients have normal pulmonary breath sounds, no abnormal findings in lung ultrasound, and deep vein proximal thrombosis in the lower limbs, combined with the patient's symptoms and cardiac hyperformance, the accuracy of acute pulmonary embolism can reach more than 90%. Dr. Sheng said with confidence.
"How do I need to treat my pulmonary embolism, don't need surgery?" Xiao Zhang will feel that his chest tightness is better, and he lifted the oxygen mask and asked the doctor worriedly. Acute pulmonary embolism is divided into three levels: high-risk, medium-risk, and low-risk. High risk refers to pulmonary embolism with hypotension, shock, such patients often have to actively take thrombolytic therapy, that is, from the intravenous bolus of thrombolytic drugs, the pulmonary artery thrombosis dissolved. For women, it is recommended unless it is a life-threatening pulmonary embolism due to the possibility of bleeding complications. Xiao Zhang's blood pressure is good, but the right heart function is abnormal, breathing has an impact, belongs to the middle-risk patients, only need to use anticoagulation therapy, of course, do not need to consider interventional and other surgical treatment options.
In this case, only need to be given twice a day low molecular weight heparin subcutaneous injection can be done, followed by the transition to warfarin oral administration. Warfarin is a vitamin K antagonist that has an anticoagulant effect. Because it can cross the placenta, it has risks such as teratogenicity, so pregnant women cannot use it. But it does not enter the milk, so it can be used for breastfeeding mothers. Note that neither pregnant women nor those who need to breastfeed should use new oral anticoagulants such as rivaroxaban, dabigatran, etc.
Although most of the acute pulmonary embolism can be relieved in about a week, it is not a good idea, and women still need oral warfarin for at least 3 months to prevent recurrence of pulmonary embolism. Here also remind the majority of pregnant women, pay attention to more activities of the lower limbs, especially after childbirth, but also to walk more on the ground, do not stay in bed "confinement".
Author: Songjiang Hospital, Shanghai Jiao Tong University School of Medicine
Emergency Critical Care Department
Li Xiangying Wang Xuemin