Pulmonary Embolism: The Battle to Save Life in a Resource Poor Setting.

Inroduction: Pulmonary embolism (PE) is a cardiovascular emergency caused by occlusion of one or more pulmonary arteries by thrombi that originate from a deep venous thrombosis (subsequently called an embolus), typically in the large veins of the lower limb or pelvis. It is a common cause of preventable hospital death and a cause of mortality in obstetrics setting because it largely remains under diagnosed especially in a resource poor setting.

Case Report: Mrs OG, a 30-year-old primigravida, had a spontaneous delivery of a baby boy. A few hours after delivery, she had two episodes of syncope and was resuscitated with intra-venous fluids and blood transfusion. Further evaluation, with an abdominopelvic ultrasound scan, showed that she had supra-levator haematoma necessitating emergency exploratory laparotomy. During the induction of anaesthesia for the surgery, she had a cardiac arrest and was again resuscitated with cardiac compression and intravenous adrenaline. She was transferred to ICU on account of cardio-respiratory instability. On the 2nd day post operation, the chest physician reviewed and noted history of cough, haemoptysis and breathlessness of two days duration. She had an associated unilateral (right) leg swelling, with presence of cyanosis, tachypnoea and tachycardia with SPO2 fluctuating between 82-92% (while on oxygen with nasal prongs). The clinical probability of PE using Well's scoring system was high (11.5). In the absence of computerized tomography (CT) pulmonary angiography and ventilation perfusion (V/Q) scan, a Doppler ultrasound of both legs was done which showed dilation of the proximal one-third of the right femoral vein with meshwork of thrombi. She was subsequently commenced on Enoxaparin and intra-venous fluids and antibiotics. She also received supplementary oxygen. The Prothrombin time and International Normalized Ratio (INR) were monitored over the period. She slowly but progressively improved and was discharged home on oral warfarin. The index patient had cardiopulmonary arrest and expectedly, needed urgent intervention with embolectomy or thrombolytic therapy. In the absence of these, anticoagulation with vasopressor agents, supplementary oxygen and close monitoring was able to sustain the patient.

Summary: Pulmonary embolism is a killer condition with 10% of the patients dying within one hour of onset. Most times, mortality occurs in patients who were never diagnosed. The best prospect for reducing mortality in patients with PE lies in improving diagnosis.