Perioperative management for cesarean section in a patient with pulmonary thromboembolism due to deep venous thrombosis

It has been estimated in Japan that Western-life style increases maternal mortality because of pulmonary thromboembolism (PTE). We report a 29-year-old primipara who suffered PTE due to deep venous thrombosis (DVT) in her 29th weeks' gestation. Except for slight tachypnea, she was relatively stable. Anticoagulation with heparin was started immediately. The retrievable inferior vena cava filter (IVC-F) was inserted. Four hours before surgery with discontinuation of heparin, the cesarean section was performed under general anesthesia. We used transesophageal echocardiography, a pulmonary artery catheter and end tidal CO2 monitoring for early detection and rapid management of recurrent PTE. She had no trouble during operation and her baby was born without serious symptoms. After recovery from anesthesia, she was admitted to the intensive care unit. Heparin was restarted after confirmation of hemostasis. On the 3rd postoperative day, we started thrombolytic therapy with urokinase which was tapered off during a week. Heparin was switched to warfarine gradually. On the 10th postoperative day, IVC-F could not be removed because of remaining DVT. She was discharged on daily warfarine. We experienced the perioperative management for cesarean section at 29 weeks' gestation following PTE due to DVT.