Leg massage during pregnancy with unrecognized deep vein thrombosis could be life threatening: a case report

Abstract

Background: Traditional massage seems to be safe but not entirely risk free, though serious adverse events are very rare. This report is aimed at illustrating a rare but fatal presentation of massive pulmonary embolism caused by leg massage and also to encourage both massage providers and pregnant women to be aware of undetected or subtle deep vein thrombosis, which could be a life threatening condition as a consequence of leg massage. Case presentation: A 25-year-old primigravid Thai woman underwent massage at a traditional massage shop at 25th week of gestation. Shortly after leg and foot massage, she had a sudden onset of dyspnea, followed by consciousness alteration, brief spastic-like convulsion, became unconscious and suffered a cardiac arrest. Basic life support (BLS) at the event scene as well as during transfer and advanced cardiovascular life support (ACLS) at the hospital were provided, resulting in successful resuscitation but persistent coma. Bedside echocardiography showed poor contractility of the dilated right ventricle, and pulmonary embolism was suspected. CT angiography (CTA) revealed multiple concentric intraluminal filling defects within the right and left pulmonary arteries, indicating massive pulmonary embolism. The fetus died in utero and spontaneous labor and vaginal delivery occurred. Conclusion: Leg massage in patients with deep vein thrombosis can dislodge thrombi, leading to life threatening pulmonary embolism, and should be contraindicated. Since pregnant women are at a higher risk of undetected or subtle thromboembolism, traditional massage in pregnant women should be contraindicated unless they are proven to have no such risk.

Expert Consensus on the Contraindications and Cautions of Foam Rolling—An International Delphi Study

“…The most recent of these case studies reported that leg massage during pregnancy with unrecognized deep vein thrombosis can dislodge thrombi, leading to a life-threatening pulmonary embolism. Massage of the lower extremity in cases of deep venous thrombosis is therefore contraindicated according to the authors [56]. Consequently, as foam rolling potentially leads to similar mechanical forces as massage, the panelists' evaluation of deep vein thrombosis as a contraindication of foam rolling is in line with the above mentioned case reports and studies.…”

“…The application of mechanical forces through modalities such as manual therapy or massage can potentially mechanically dislodge a thrombus, as reported by various case reports [53][54][55][56]. The most recent of these case studies reported that leg massage during pregnancy with unrecognized deep vein thrombosis can dislodge thrombi, leading to a life-threatening pulmonary embolism.…”

Effects, Side Effects and Contraindications of Relaxation Massage during Pregnancy: A Systematic Review of Randomized Controlled Trials

“…DVT can be difficult to diagnose, as its symptoms can be very similar to discomforts that accompany normal pregnancies, like swelling of the legs and back pain. Leg massage during pregnancy with unrecognized DVT can be life threatening [56]. Therefore, no massages should be performed on the deep muscle tissue of the arms and especially not the legs, in order to avoid loosening blood clots or causing hematomas.…”

“…Therefore, no massages should be performed on the deep muscle tissue of the arms and especially not the legs, in order to avoid loosening blood clots or causing hematomas. However, superficial lymphatic drainage and gentle stroking touches to alleviate edemas are allowed [56].…”

Massage During Pregnancy and Postpartum

“…Pregnancy is a prothrombotic state, and women are at increased risk for formation of deep vein thromboses during pregnancy and the postpartum period. Women with pregnancies complicated by deep venous thromboses, especially of the lower extremities, are cautioned to avoid massage because of the possibility of displacing blood clots and increasing the risk of pulmonary embolus 54. There are no massage studies that specifically investigate women with “high-risk” conditions such as gestational diabetes, hypertension, vaginal bleeding or suspected chronic placental abruption during pregnancy and labor and more research on the safety and efficacy of massage in this cohort is needed.…”