BackgroundPulmonary embolism (PE) resulting from venous thromboembolism is a leading cause of maternal mortality in pregnancy. In patients with massive PE and hemodynamic instability, the treatment options often considered are thrombolytics, inferior vena caval filters, or embolectomy. We report here the case of a patient with massive PE at 28 weeks’ gestation, who underwent emergency pulmonary embolectomy via cardiopulmonary bypass.Case presentationA 35-year old primigravida with a history of massive PE at 25 weeks of gestation was referred to our hospital at 28 weeks of gestation, following treatment failure after insertion of an inferior vena cava filter and heparin administration. Emergency thrombectomy was performed, and intracardiac echography was used for intraoperative fetal heart rate monitoring. However, the patient developed hemodynamic collapse following anesthesia induction; hence, emergency cardiopulmonary bypass (CPB) was performed via median sternotomy. Thrombectomy and tricuspid valve plication were performed under cardiac arrest. After confirming postoperative hemostasis, heparin administration was resumed. At 40 weeks of gestation, labor was induced under epidural analgesia. Both mother and child were discharged with no complications.ConclusionIn conclusion, intracardiac echography is useful for fetal heart rate monitoring during emergency cardiac surgery in pregnancy. Careful CPB management is important to maintain uteroplacental blood flow. Although there is no consensus on the delivery methods in such cases, epidural analgesia during labor was useful in reducing cardiac load and wound traction.

Purpose: Opioids are concerned as a major cause of postoperative respiratory depression. In the immediate postoperative period, however, other factors can produce instability of breathing such as pain, agitation, and residual effects of anesthetics. Such factors might be overlooked masked by the fear for opioid-induced respiratory depression. We report a case who presented apnea immediately after emergence from anesthesia that we considered was produced by an interaction among such factors accompanied with fentanyl-induced respiratory depression. Clinical Features: A 31-year-old woman underwent ovarian cystectomy under general anesthesia with continuous infusions of propofol and remifentanil, and bolus doses of fentanyl. Transversus abdominis plane blocks with ropivacaine were given upon completion of surgery. She complained of severe wound pain and was agitated at the emergence from anesthesia. Fentanyl 50 µg was administered intravenously. In several minutes, she developed apnea, unconsciousness, and difficulty of mechanical ventilation via a face mask. The estimated effect site concentration at the onset of the episode (2.9 ng•ml −1 ) was approximately the same (3.0 ng•ml −1 ) as after 30 min when she regained consciousness and spontaneous breathing. It indicated that not only direct inhibition of the respiratory center by fentanyl but also other stimulatory and inhibitory factors contributed to respiratory arrest. Conclusion: In the immediate postoperative period, transient factors, such as pain, mental instability and anesthetic residues, which are indirectly-related with breathing, can interact each other and with opioids. The interaction would induce apnea through mechanisms combined among direct inhibition of the respiratory center, and modulation of chemical and cortical controls of breathing.

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Systemic mastocytosis is a life-threatening disease in which mast cell mediator release can lead to general symptoms. The most common triggers are stress and pain during labor and delivery. We report the management of labor and delivery in a case with severe systemic mastocytosis by epidural analgesia.