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 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 travelled 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 [5,6,7,8]. 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 [5,6,7,8]. 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 [5,6,7,8].
The important clinical learning point gained from this case report is that 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. More importantly, 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, paradoxical motion of the interventricular septum, pulmonary artery dilatation, elevated pulmonary pressures, empty left heart and, rarely, a right heart thrombus .
The timing of symptom development in relation to trigger activity was a very unique feature. The onset of cardiovascular collapse was shortly after leg massage, highly suggestive of thrombus embolization. Unlike most previous case reports of leg massage, concerning induced pulmonary embolism that occurred in previously known cases of deep vein thrombosis in non-pregnant patients [2,3,4], the case presented here is the first case report of leg massage leading to thrombi dislodge with the consequence of severe morbidity in a healthy pregnant woman who had undetected preexisting deep vein thrombosis, which was likely aggravated by physiologic changes during pregnancy. Unfortunately, our patient had not attended antenatal clinic before the event. Thus, she had no chance of undergoing thrombotic risk assessment (Caprini score) in early gestation. If the assessment showed high risk of thromboembolism, preventive anticoagulant might have been helpful. It is noteworthy that not only the mother but also the fetus life was threatened following pulmonary embolization. Fetal distress was detected shortly after admission. This is not unexpected since fetal distress is common after catastrophic events leading to hypoxia in the mother. Certainly, some degree of maternal hypoxia can cause a decrease in placental perfusion, resulting in fetal distress and death finally. In spite of maternal improvement after resuscitation, fetal distress may not always subside because of prior prolonged fetal asphyxia. The resuscitation improved hemodynamics in maternal vital organs but did not restore placental circulation. The decision of cesarean section due to fetal distress in this case was challenging. Several concerns were taken into considerations; for examples, the survival rate of the baby at 25 weeks of gestation in our center, which was about 25%, or much lower in cases of fetal distress, together with high morbidity, additional risk to the patient secondary to cesarean section or hemorrhage which could worsen her life-threatening condition. We followed the standards of care and medical ethics, comprehensive counseling was provided by the care team and the decision was based on the principles of autonomy and nonmalefficience.
In our country, traditional massage is widely practiced without proper guidance by local governmental agencies. Accordingly, several laypersons without adequate training practice traditional massage, and many massage shops are operated without governmental control. Similar to any other medical therapy, traditional massage may be associated with adverse effects, and it is an issue that needs to be studied further. Based on this report and literature review, strict control of our traditional massage by governmental agencies is needed, and the practice needs standardization.
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.