Pregnant patient with pulmonary embolism

garychleung

PIG Meeting: 25th February 2021

34yo patient for elective CS, complex chronic and acute health problems.

Background

  • Ehlers Danlos Syndrome
    • Hypermobility type
    • ‘Marfans features’ (but not Marfans) with lens dislocation, high arched palate, spontaneous L PTx and known small bullae on R.
    • Bowel and gastric stasis requiring caecostomy.
  • Central and obstructive OSA – adherent to CPAP
  • BMI 38
  • Uveitis HLAB27 +
  • Raynaud’s phenomenon
  • Pregnancy – G1P0, nil foetal complications.

Issues

  •  PE – clinical symptoms + V/Q mismatch. On therapeutic clexane since ~10/7
  • ? Risk of aortic root aneurysm
    • Somewhat unusual picture. Risk difficult to quantify
    • Minimal harm from TTE (n.b. normal aortic root on subsequent TTE).
  • Risk of local anaesthetic failure
    • Patient has previously had some failed peripheral nerve blocks but successful rescue blocks

Discussion

  • What is Ehlers Danlos Syndrome?
    • The most common group of disorders in the family of genetically determined heritable connective tissue disorders.
    • Ligament laxity, joint hypermobility, fragility of connective tissues, poor wound healing.
    • Multiple subtypes with cardiac, GIT, autonomic and chronic pain issues.
  • Anaesthetic technique
    • Morphine adverse drug reaction (rash).
    • Neuraxial ideal. Consider CSE as colorectal team on standby given previous bowel surgery.
    • TAP catheters useful to avoid opioid exacerbation of gut stasis postop + risks of resp depression with opioids. Some reports of ineffective or partially effective LAs however not contraindicated and may provide substantial benefit.
    • If GA required, lung protective ventilation to minimise risk of bullae rupture. 
    • Note that Ehlers Danlos patients also have increased risk of bleeding post-operatively
  • Postoperative location (? Delivery suite, ? K2)
    • High VTE risk postop however this risk continues for weeks so no specific observation needed.
    • OSA well optimised
    • Normal care on K2 reasonable
  • Anticoagulation management
    • Discussed ? Need for conversion to heparin given known PE, to minimise time off anticoagulation
    • Overall thought that 24h off clexane reasonable and the logistics in starting/stopping heparin make it of limited value for this short period of time.