Leg massage during pregnancy with unrecognized deep vein thr
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A 25-year-old primigravid 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.

Due to sudden onset of dyspnea, consciousness alteration and cardiovascular collapse during massage manipulation of the patient’s leg, which was later proven to have a pulmonary embolism and deep vein thrombosis, it is reasonable to conclude that the patient had undetected preexisting deep vein thrombosis, which was mechanically dislodged by the massage and traveled massively to both lungs, leading to a life-threatening condition. However, differentiation from other causes of sudden dyspnea should be considered, including heart failure, ischemic heart, pericarditis, pneumonia, pneumothorax, exacerbation of chronic lung disease, and musculoskeletal pain.

For patients suspected of pulmonary embolism, tests including ECG, chest film, brain natriuretic peptide and troponin levels, and arterial blood gases are often helpful in differential diagnosis and management. However, a diagnosis of pulmonary embolism should be confirmed by CTA or magnetic resonance pulmonary angiogram. Patients who are highly suspected of having this condition and unstable hemodynamics must be fully resuscitated, given anticoagulation and diagnostic imaging. For cases that remain unstable despite resuscitation, bedside echocardiography and compression ultrasonography with Doppler of the leg veins should be used to make a rapid diagnosis to justify the administration of potential life-saving treatment, including thrombolytic agents.

The important clinical learning point gained from this case report is
-Massage of the lower extremities in cases of deep venous thrombosis is contraindicated as it can dislodge the thrombus and can cause a life-threatening pulmonary embolus.
-pregnant women are in a physiologic hypercoagulable state and are at a higher risk of thromboembolism.

Pregnancy can place patients with preexisting undetected or subtle deep vein thrombosis at a higher risk of pulmonary embolism. Therefore, pregnant women should be advised to avoid leg massage unless they are certain that no thromboembolism disorders exist. This case report should encourage professional massage providers to be aware of subtle preexisting deep vein thrombosis, especially in pregnant women. This case also provides an additional learning point by illustrating the role of bedside echocardiography in right ventricular evaluation in massive pulmonary embolism. Though echocardiography is generally not considered a diagnostic tool for pulmonary embolism, in unstable patients with massive pulmonary embolism, echocardiography for right ventricular evaluation can be used as a diagnostic tool.

Furthermore, echocardiography is also useful in risk categorization and prognosis in pulmonary embolism. The echocardiographic features suggesting pulmonary embolism are poor contractility of the right ventricle, right ventricular dilatation, tricuspid regurgitation, the paradoxical motion of the interventricular septum, pulmonary artery dilatation, elevated pulmonary pressures, empty left heart and, rarely, a right heart thrombus.

In conclusion, leg massage in patients with deep vein thrombosis can dislodge thrombi, leading to life-threatening pulmonary embolism; therefore, it should be contraindicated. Since pregnant women are at a higher risk of undetected or subtle thromboembolism, traditional leg massage in pregnant women should be contraindicated unless they are proven to have no such risk.

Source: https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-020-02924-w
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