Abstract | November 17, 2023
Maternal Cardiac Arrest Secondary to an Avulsion of the Ovarian Vein from the Inferior Vena Cava ian vein from the inferior vena cava.
Learning Objectives
- Respond to maternal cardiac arrest and prioritize specialized training and collaboration from a multidisciplinary team to improve event outcomes. Maternal cardiac arrest is a rare but catastrophic medical emergency associated with a high mortality rate, but this rate can be improved with early detection and and appropriate action.
- Appropriately weigh the risk of recurrent or additional dissection in future pregnancies in patients with history of postpartum hemorrhages due to arterial dissections. These patients should be considered high risk and be monitored closely during the immediate postpartum period.
- Broaden the differential diagnosis for patients with suspected postpartum, intraabdominal hemorrhage to now include avulsion of a gonadal vein as a potential source of hemorrhage. Rupture of an ovarian aneurysm, a previously well characterized etiology, presents clinically similar to an avulsion of a gonadal vein as occurred in this patient, with comparable hemodynamic instability and development of a retroperitoneal hematoma(4). Both are rare and life-threatening. Therefore, both rupture of an ovarian aneurysm and avulsion of a gonadal vein should both be considered as differential diagnoses for a patient with concern for intra-abdominal hemorrhage in the immediate postpartum period.
Introduction: Maternal cardiac arrest is a rare but catastrophic event associated with high mortality (1,2). One cause is hemorrhagic shock secondary to postpartum hemorrhage (3). We present a case of a patient who underwent cardiac arrest in the immediate postpartum period secondary to an avulsion of the right ovarian vein from the inferior vena cava (IVC).
Case Presentation: A 38-year-old G5P4004 patient was admitted at 40w1d for induction of labor. Her pregnancy was complicated by postpartum hemorrhage in a prior delivery secondary to a left ovarian artery pseudoaneurysm, substance use disorder, preeclampsia with severe features and Kell isoimmunization. Her labor course was unremarkable resulting in a vaginal delivery of a healthy male infant; however, she had uterine atony that required uterotonics. Ten hours after delivery, the patient was obtunded with a diffusely tender abdomen, vital signs normal. Bedside ultrasound identified significant bladder distension, assumed to be causing her pain. The bladder was drained, and within 5 minutes the patient became unresponsive and went into cardio-pulmonary arrest. Resuscitation efforts were initiated immediately. Return of spontaneous circulation was achieved after 2 minutes.. CT Abdomen/Pelvis showed a large right retroperitoneal hematoma with extension into the mesentery measuring 21.5 x 15.0 cm. She was taken for an exploratory laparotomy by a multidisciplinary team including maternal fetal medicine, gynecologic-oncology, and vascular surgery. Intraoperative findings were remarkable for a 3.5 L retroperitoneal hematoma secondary to the avulsion of the right ovarian vein at the level of the IVC. This was repaired and she received blood product resuscitation. Postoperatively, she was transferred back to the intensive care unit in stable condition and subsequently discharged on post operative day 4.
Final/Working Diagnosis: Maternal cardiac arrest secondary to an avulsion of the ovarian vein from the IVC.
Management/Outcome/and or Follow-up: Despite experiencing cardiac arrest, the patient’s outcome was favorable due to early detection and management. At 4 weeks postpartum, she was meeting all milestones. Given this patient’s history of two vascular events, genetic arterial aneurysm and collagen panels were ordered, which were negative.
References and Resources
- 2015;132(18):1747-1773. doi:10.1161/CIR.0000000000000300
- Jakubow AN. The occasional maternal cardiac arrest. Canadian Journal of Rural Medicine. 2021;26(3):128. doi:10.4103/cjrm.cjrm_70_20
- Mhyre JM, Tsen LC, Einav S, Kuklina EV, Leffert LR, Bateman BT. Cardiac Arrest during Hospitalization for Delivery in the United States, 1998–2011. Anesthesiology. 2014;120(4):810-818. doi:10.1097/ALN.0000000000000159
- Enakpene CA, Stern T, Barzallo Salazar MJ, Mukherjee P. Spontaneous Rupture of an Ovarian Artery Aneurysm: A Rare Postpartum Complication. Case Reports in Obstetrics and Gynecology. 2016;2016:e1029561. doi:10.1155/2016/1029561
