Pulmonary Embolism During Pregnancy: A Mom's Difficult Decision
Late at night on Feb. 11, 2015, an ambulance raced up I-95 toward Yale New Haven Hospital.
The day before, Victoria Roa, 38 weeks pregnant, had felt dizzy when she went to lift her young son, Nicholas, out of his crib. Her chest hurt, and she struggled to breathe. She called to her fiancé for help, and then telephoned her obstetrician. He told the 33-year-old resident of Harrison, N.Y., to go straight to the emergency room.
Roa went to Greenwich Hospital, where she had planned to deliver her baby. Nurses clocked her heart rate at 220 beats per minute. It took two days and a barrage of tests for doctors to discover the cause of her symptoms: a pulmonary embolism. A large blood clot in Roa’s lungs was blocking her breathing and stressing the right side of her heart. Her life was in immediate danger.
“They said they couldn’t handle the situation there, they were going to rush her to Yale,” says Roa’s younger sister, Maria Lagani.
When Roa’s ambulance reached the hospital, a team of doctors and nurses from Yale Medicine ran out to meet it. As they admitted her and started planning her treatment, they asked her a painfully difficult question. “If they could only save one life—mine or my baby’s—which did I want them to save?” Roa says.
The hardest question
Pulmonary emboli can have a high fatality rate when a patient has very low blood pressure or an overly slow heart rate. “In a patient at term pregnancy, our treatment options are extremely limited, and both the patient’s and baby’s life are in peril,” says Yale Medicine’s Leon Freudzon, MD, an assistant professor in anesthesiology at Yale School of Medicine, who was part of the team helping Roa.
Roa’s clot had probably started in a vein in her leg. This is not uncommon in pregnant women, because the uterus can obstruct blood flow to the lower extremities, leading to what is called a deep vein thrombosis. Roa’s baby had been putting pressure on her right hip, and she had had to leave her job as a massage therapist before her planned maternity leave. She had been using crutches to get around. Her limited mobility may have contributed to the formation of the clot.
“Occasionally, the clots can travel up to the heart and lungs,” says Pramod Bonde, MD, a Yale Medicine cardiac surgeon and an associate professor of surgery at Yale School of Medicine, who also cared for Roa. “They reduce the amount of blood going to the left side of the heart, and put a lot of stress on the right side.”
When Roa arrived at Yale, her heart was struggling against the clot. Her life, and that of her baby, hung in the balance.
Still, Roa did not hesitate when answering the caregivers’ question. “I told them to save my son, without a doubt,” she says. “I’d lived. He hadn’t lived yet. I wanted him to get a chance at life. I didn’t want him to die.” But Roa’s mother, Deborah Tarasoff, objected, equally protective of her daughter’s life. She insisted that they call Roa’s fiancé, Gerald, who was at home with the couple’s other child. The two begged her to change her mind. “They both said, ‘Without you, it will be hard for the baby to survive,’” she says. “We have to save you.” She finally acquiesced.
A multidisciplinary team assembled for a meeting. The physicians included a maternal-fetal specialist, Katherine Kohari, MD; the heart surgeon, Dr. Bonde; the cardiac anesthesiologist, Dr. Freudzon; and Ferne Braveman, MD, director of the Department of Obstetrics & Gynecology Anesthesiology. “We discussed the case at length to figure out the safest thing to do,” Dr. Freudzon says.
“There were no egos,” Dr. Braveman says. “The entire team of physicians and nurses was focused on doing the best thing for the mom and the baby. Because we didn’t have one patient, we had two.”
The team’s main concern was that Roa’s heart could stop at any moment. The usual medical response to a stopped heart is CPR. “It doesn’t work as well for a pregnant woman,” Dr. Freudzon says. “Because you have a baby in there, it prevents the return of the blood to her heart. CPR would not rescue her.” If Roa’s heart stopped, she and the baby could die.
Another worry was that Roa would go into labor, further stressing her heart and making it difficult for the team to mobilize for cardiac anesthesia and heart surgery.
Also a problem: Roa was taking blood thinners to keep the clot from growing. Those medications could cause excessive bleeding if the Yale Medicine team performed a cesarean section (C-section). “We were between a rock and a hard place,” Dr. Braveman says.
They had a few tough options, says Dr. Bonde. One was to do what would be typical for most hospitals: Watch and wait to intervene. If the heart failed, a surgeon would crack open the patient’s chest to deal with the clot and the stopped heart. With this approach, “The expected mortality for the mother and the baby would be very high,” Dr. Bonde says. Another possible choice was to attempt to extract the clot through surgery, but the expected outcome of that procedure was not much more hopeful.
A plan with more hope
Eventually, Roa’s extremely precarious position forced an action. “We didn’t know how much strain the right side of her heart could take,” Dr. Freudzon says.
Dr. Bonde said that they would have the best chance for a healthy baby and healthy mother if they did a C-section, but one performed in a way to save Roa’s life in case her heart stopped. “We decided that instead of CPR, we’d do cardiopulmonary bypass,” Dr. Freudzon says.
It had to be carefully planned. Before doctors started the C-section, they would place catheters in blood vessels in Roa’s groin. If her heart stopped during the surgery, her blood could immediately be diverted to a machine that would oxygenate it and return it to her body.
This approach required Dr. Bonde to use his specialized training and advanced equipment to suction out the clot through the catheters. “We could save both the mother and the baby, without doing any harm to them,” he says.
Everyone in the operating room was ready to step in if their skills were needed. “They told us how they planned to do everything,” Roa says. “They were going to try to save the baby, too. We thought, ‘We’ll see how it goes down.’”
An unconventional birthday
The operation was done in the cardiac operating room. Regional anesthesia was not an option because of the blood thinners Roa was taking. “You can’t safely put in a spinal or epidural catheter, because you might get bleeding around the spinal cord,” Dr. Freudzon says. Instead, he administered general anesthesia. Once Roa was safely sedated, Dr. Bonde made the incisions to insert the catheters into her groin.
Meanwhile, Roa’s mother and sister huddled in the waiting room. About two hours into the procedure, a doctor hurried out with some news. “They got the baby,” he said. “Come! Come! They’re taking him to the NICU (neonatal intensive care unit).”
Tarasoff and Lagani rushed over to catch a glimpse of the family’s newest addition. “He was all wrapped up in blankets with a hat on his head,” Lagani says. “He was very out of it, because he got a lot of the general anesthesia. They had him all tubed up and were breathing for him.”
They asked, “What’s going on with Victoria?” The doctor replied: “They’re working on her now. Someone will come out and talk to you.”
‘Keep breathing, keep breathing’
A torturous hour and a half ticked by before another doctor came out to speak with the two women. The doctors were still working on Roa, and he explained what they were doing.
Two hours later, they received a phone call from the doctor. “They said she’d been taken back to the ICU, and we should go there,” Lagani says. The women rushed over, and waited outside Roa’s room while the care team settled her in. Finally, they were allowed to come closer.
“That was one of the hardest times,” Lagani says, a sob catching in her throat. “She was yellowish, and had tubes in because a ventilator was breathing for her. She looked like the person who didn’t make it.”
Still, the Yale Medicine doctors seemed optimistic, explaining how things had gone in the operating room and what they were doing for her. They left her in the hands of the ICU nurses, who were “amazing,” Lagani says. “They were so comforting,” she says.
As one nurse attended to Roa, the ventilator buzzed, scaring her mother and sister. “That means she’s overbreathing the ventilator,” the nurse says. “That’s a good sign.”
“My mom and I were talking to her,” Lagani says. “Saying, ‘Keep breathing, keep breathing. Keep fighting.’”
Two lives saved
Despite her life-threatening condition and the challenging surgery, Roa was doing better than anyone had dared to hope. Losing some blood during the surgery had actually improved her heart dynamics.
The doctors hoped that Roa would continue to improve after the baby’s birth, which meant her blood volume could slowly return to normal. If everything continued to go well, they could allow her body to break down the clot itself, without further medical intervention.
The day after her C-section, Roa was awake and breathing well enough to come off the ventilator. In the NICU, her baby, Joseph, had his breathing tube removed, and was taking his first gulps of air. Mother and son could finally meet.
“I started crying the moment they brought him in,” Roa says. “I was absolutely hysterical. I said: ‘Oh my God, what you put me through! I love you!’”
The two spent more time bonding the next day, Sunday, Feb. 14. “That was the best Valentine’s Day present I ever got in my life,” she says.
By the following Tuesday, Joseph was healthy enough to go home to his father and his big brother. Roa needed a few more days to convalesce and went home on Thursday. “I couldn’t believe how well I was treated at Yale,” she says. “Even after discharge, they were all calling me afterward. How was I doing? Did I have any questions? The doctors and nurses were all amazing.”
A few weeks later, Lagoni emailed Dr. Bonde photos of Joseph, on behalf of her sister. “My family and I couldn’t be more grateful for the team of doctors who saved her life,” she told him. “Thank you for all you have done!”