Case Reports Postcesarean Pulmonary ducted a systematic, all-language literature review using Ovid (MEDLINE, Fulltext, and Cochrane), Embolism, Sustained Inspire, MD Consult, and UpToDate search engines, Cardiopulmonary Resuscitation, and other expert search strategies, from 1966 to Embolectomy, and Near-Death December 2004. Experience CASE Alan T. Marty, MD, Frank L. Hilton, MD, Under epidural anesthesia a 31-year-old G2, P2, Ab0 woman underwent a repeat cesarean delivery and delivered a Robert K. Spear, MD, and Bruce Greyson, MD 3.178-kg male infant. She had no complications until 1040 the next morning when she collapsed after standing up. Her BACKGROUND: Survival after surgical embolectomy for blood pressure initially was unobtainable and then rose to 50 massive postcesarean pulmonary embolism causing sus- to 60 mm Hg systolic. Her pulse rate was 130 to 140; she tained cardiac arrest is rare. appeared breathless and complained of substernal chest pain. CASE: One day after an uneventful cesarean delivery, a Her nail beds were blue. She was alert, cooperative, and woman developed cardiac asystole and apnea due to anxious. Breath sounds were equal on both sides of the chest. pulmonary embolism. Femoral-femoral cardiopulmonary Oxygen, intravenous fluids, heparin, and dopamine were bypass performed during continuous cardiopulmonary administered, but her blood pressure remained at 60 mm Hg. resuscitation allowed a successful embolectomy. Upon An electrocardiogram showed severe right-axis devia- awakening, the patient reported a near-death experi- tion. A radial arterial line was placed and a pulmonary ence. Pulmonary embolism causes approximately 2 arteriogram was performed. During the pulmonary angio- deaths per 100,000 live births per year in the United gram, which showed bilateral pulmonary emboli with States, and postcesarean pulmonary embolism is proba- complete obstruction of the right pulmonary artery and bly more common than pulmonary embolism after vag- essentially complete obstruction of the left pulmonary inal delivery. artery except for a small upper lobe branch (Fig. 1), she suddenly stopped breathing, and her electrocardiogram CONCLUSION: Massive pulmonary embolism is a po- monitor displayed many premature ventricular contractions tentially treatable catastrophic event after cesarean de- and then asystole. Cardiopulmonary resuscitation (CPR) livery, even if continuous cardiopulmonary resuscitation was begun, and the patient was transferred to the operating is required until life-saving embolectomy is done. room with continuous CPR. Her pupils were dilated and (Obstet Gynecol 2005;106:1153–5) unresponsive to light. While she was having closed chest cardiac massage, the left inguinal region was prepared, draped, and incised. Two ulmonary embolism is the leading cause of mater- large cannulas were inserted into her femoral artery and nal death following a live birth.1 The few reported P vein, and cardiopulmonary bypass was begun at 1210— cases of successful surgical pulmonary embolectomy approximately 90 minutes from the time she collapsed in after cesarean delivery have not occurred in the her room and 45 minutes after CPR had begun. Initial United States. Additionally, near-death experiences bypass flows were 2 to 2.5 L/min. The chest was then after pulmonary embolectomy have not been previ- prepared and draped, and a sternotomy was performed ously reported in the medical literature. We con- while core cooling was done by cardiopulmonary bypass. The right heart appeared massively dilated and was not beating. A second venous cannula was inserted into the See related editorial on page 1147. right atrium to augment venous return and to decompress the right heart. Cardiopulmonary bypass flows then in- From the Departments of Cardiac Surgery, Obstetrics and Gynecology, and creased to 4 L/min. The aorta was cross-clamped and blood Pulmonary Medicine, Saint Mary’s Medical Center, Evansville, Indiana, and the Department of Psychiatric Medicine, Division of Personality Studies, cardioplegia was instilled into the aortic root. The main University of Virginia, Charlottesville, Virginia. pulmonary artery was clamped proximally and then Corresponding author: Alan T. Marty, MD, 214 West Water Street, Newburgh, opened distally. Both pleura were then opened and both IN 47630; e-mail: [email protected]. lungs were compressed manually to express the emboli out © 2005 by The American College of Obstetricians and Gynecologists. Published retrograde through the pulmonary arteriotomy. Twenty-six by Lippincott Williams & Wilkins. blood clots measuring up to 1.5 cm in diameter and 6 to12 ISSN: 0029-7844/05 cm long were extracted. Pathologic examination showed VOL. 106, NO. 5, PART 2, NOVEMBER 2005 OBSTETRICS & GYNECOLOGY 1153 second dose of warm blood cardioplegia the pulmonary arteriotomy was sutured, the aortic cross-clamp was re- leased, and the patient was rewarmed. Her heart returned into sinus rhythm, and she was weaned from cardiopulmo- nary bypass. The total cross-clamp time was 35 minutes; bypass time was 70 minutes. The chest was closed, the femoral cannulas were removed, the left femoral vessels were repaired, and she was transferred to the cardiac recovery room. The next morning a brain scan and an electroencepha- logram showed normal results. While still intubated in the recovery room, she then awoke and moved her hand in a way that indicated she wanted to write something. Her handwritten note described details of her near-death expe- rience: “I saw Jesus when I fell in the floor the 1st time. I went to heaven out the window. Other room. I saw a cross. Then He came and got me.” Then she turned the paper over and drew a picture of the diamond cross. Later that day she was extubated and described the near-death experience in more detail: she had died 3 times, Fig. 1. Pulmonary angiogram showing nonfilling of the right or had gone to heaven, and had seen Jesus and 2 deceased left pulmonary arteries, with filling of a dilated right atrium, relatives. Heaven was described as a very pleasant place right ventricle, and main pulmonary outflow tract. The con- from which she did not care whether she returned to earth, trast material has refluxed back into the right heart due to but Jesus told her to return to take care of her children. Her obstruction of all the main pulmonary artery branches. oral description of the near-death experience was tape- Marty. Pulmonary Embolectomy and Near-Death Experience. Obstet Gynecol 2005. recorded soon after she could talk. To prevent recurrent pulmonary emboli, 2 days after her pulmonary embolectomy a “Bird’s Nest” venous filter was the clots to be of different ages, some fresh and some placed percutaneously in the inferior vena cava just below the organized with layers of white cells. After instilling a renal veins. Anticoagulation was continued with heparin until EMBOLECTOMY FOR POSTCESAREAN PULMONARY EMBOLISM NEEDING CARDIOPULMONARY RESUSCITATION (CPR) A. Outcomes when cardiopulmonary bypass started during continuous CPR 1. Brain death occurred—Aleksic I, Baryalei MM, Schorn B, Busch T, Strauch J, Weyland A, et al. Heart transplantation after successful donor postpartum pulmonary embolectomy. Chest 1999;115:1202–3. (Germany) 2. Discharged 1 month postoperatively—Ookawa Y, Kamata K, Tanaka A, Maekawa K, Watanabe N. A case report of massive pulmonary embolism with cardiac arrest at ICU—the effect of emergency percutaneous cardiopulmonary support system. J Jap Assoc Thorac Surg 1993;41:1035–39. (Japan) 3. Retrograde amnesia, discharged 9 days postoperatively—Marty et al. Present report. (United States) B. Outcomes when surgery done for unstable hemodynamics after CPR(s) 1. Discharged to neurorehabilitation unit—Grundmann U, Bach F, Wendler O, Friedrich M, Ertan AK. Fulminant pulmonary embolism following caesarean section. Der Anesthetist, 2000;49:1034–37. (Germany) 2. Ruptured liver, discharged 41 days postoperatively—Ilsaas C, Huspy P, Koller ME, Segadal L, Holst-Larsen H. Cardiac arrest due to massive pulmonary embolism following caesarean section. Successful resuscitation and pulmonary embolectomy. Acta Anaesthesiol Scand 1998;42:264–66. (Norway) 3. Ruptured liver, discharged 42 days postoperatively—al-Ebrahim K, Bolwell J, Helmy A, Shafei H. Postpartum pulmonary embolectomy; a surgical challenge and favourable outcome. Thorac Cardiovasc Surgeon 1997;45:38–9. (Saudi Arabia) 4. Retrograde amnesia, discharge day unstated—Krejci V, Lindner J, Hajek Z, Sosna O, Blaha J, Zouhar T, et al. Massive pulmonary embolism after delivery by cesarean section. Ceska Gynekol 2002;67:3–8. (Czech Republic) 1154 Marty et al Embolectomy and Near-Death Experience OBSTETRICS & GYNECOLOGY her prothrombin times became therapeutic on warfarin. She where a score of 7 or higher defines an experience as was discharged on her ninth postoperative day and had no leg a true near-death experience.6 None of the anesthetic swelling and normal lower extremity venous duplex exami- agents that our patient received in very low doses nations thereafter. She continued to take warfarin. (fentanyl, midazolam, or scopolamine) have been Not unexpectedly, for many months after her prolonged reported to excite a reaction similar to near-death cardiac arrest, she experienced severe amnesia, and at first she experience. Neuroscientists have proposed that such did not even remember having given birth to her son. Besides her amnesia, she developed posttraumatic stress syndrome religious–numinous experiences involve endorphin- and panic attacks,