Thrombolysis for massive pulmonary embolism in pregnancy: a case report
© Fasullo et al; licensee Springer. 2011
Received: 11 March 2011
Accepted: 31 October 2011
Published: 31 October 2011
Mortality from pulmonary embolism (PE) in pregnancy might be related to challenges in targeting the right population for prevention. Such targeting could help ensure that the correct diagnosis is suspected and adequately investigated, and allow the initiation of the timely and best possible treatment of this disease. In the literature to date only 18 case reports of thrombolysis in pregnant women with PE have been reported, and showed beneficial effects for both mother and fetus in terms of mortality and complications with acceptable bleeding risks. We present here the case of a pregnant patient with massive PE who underwent successful thrombolysis. A 26-year-old pregnant (at 24 weeks) woman was admitted 4 h after onset of sudden acute dyspnea and chest pain. An immediate electrocardiogram showed a typical S1-Q3-T3 pattern. The echocardiogram showed a distended right ventricle with free-wall hypokinesia and displacement of the interventricular septum toward the left ventricle. Thrombolysis with recombinant tissue plasminogen activator (alteplase 10 mg bolus, then 90 mg over 2 h) was administered. Pelvic examination and ultrasound showed regular fetal heart beat, and regular placental and liquid presence. No problems developed for the mother or fetus in the subsequent days or at discharge. In conclusion, in pregnant patients with life-threatening massive PE, thrombolytic therapy can be administered, and the use of echocardiographic, laboratory, and clinical data can be useful tools to achieve a rapid diagnosis and make a therapeutic decision, but additional studies need to be performed to further define its use.
Massive pulmonary embolism (MPE) is the leading cause of maternal mortality in the developed world. Mortality from PE in pregnancy might be related to challenges in targeting the right population for prevention. Such targeting could help ensure that the correct diagnosis is suspected and adequately investigated, and allow the initiation of the timely and best possible treatment of this disease. Thrombolytic drugs can be considered for the treatment of patients who are hemodynamically unstable, or of patients with refractory hypoxemia  or right ventricular dysfunction on echocardiogram [2, 3]. However, the high risk of major bleeding (in 4%-14% of treated patients with thrombolysis) limits their use . Although pregnancy-specific complications do arise, including spontaneous pregnancy loss, placental abruption, and preterm labor, it is not clear whether they are caused by the underlying disease, its treatment, or neither. We present here the case of a pregnant patient with massive PE (MPE) who was hospitalized 4 h after onset of sudden acute dyspnea and chest pain, and successfully thrombolysed.
A 26-year-old pregnant (at 24 weeks) woman was referred to the emergency department (ED) of our hospital ("G.F. Ingrassia" Palermo, Italy) 4 h after onset of sudden acute dyspnea and chest pain. No risk factors or drug consumption was present in the patient's clinical history. On admission to the ED, the patient was dyspneic, cyanotic, hemodynamically unstable, hypotensive (70/50 mmHg), and tachycardic (125 beats/min), with low oxygen saturation (80%) in oxygen with a Venturi mask (6 L/min), with a respiratory rate of 28-30 breaths/min, and with primary hypoxemia and metabolic acidosis (pH 7.29; PO2 51 mmHg, PCO2 30 mmHg, HCO3 20 mmol/L).
Clinical and laboratory parameters in the first 72 h after admission.
OS (6 L/min O2)
98 (6 L/min O2)
99% room air
Women who are pregnant or in the postpartum period as well as women receiving hormonal therapy are at increased risk for venous thromboembolism. Venous thromboembolism is responsible for up to 15% of all in-hospital deaths, and it also accounts for 20% to 30% of deaths associated with pregnancy and delivery in the United States and Europe. In pregnant patients with suspected acute PE, the use of noninvasive diagnostic methods without imaging may seem ideal, but concern about exposure to radiation should not deter clinicians from using computed tomography angiography or ventilation-perfusion scanning when necessary. Although experience with thrombolytic therapy in pregnancy is limited (only 18 cases treated with different thrombolytic drugs have been reported), the use of thrombolytic agents may be lifesaving in patients with MPE and severe hemodynamic compromise [7–14]. In these 18 case reports of pregnant women treated with systemic thrombolysis for MPE, the most commonly used regimen during pregnancy was 100 mg tPA over 2 h (10 patients), while 6 patients received STK and 2 urokinase. Concerning complication rates in pregnant women (major nonfatal bleeding), only 4 of 18 cases were observed in the streptokinase group. In addition, preterm delivery occurred in two patients with tPA and three in the streptokinase group. Two child deaths were reported (1 in the streptokinase and 1 in the tPA group), but they were not attributed to fetal hemorrhage [7–14]. There is concern that thrombolytic therapy will lead to placental abruption, but this complication has not been reported. The care of the pregnant patient who has MPE either at term or when suspicion of compromised fetal status calls for expeditious cesarean delivery is complex and requires a coordinated treatment strategy by the obstetrician, intensivist, cardiothoracic surgeon, anesthesiologist, and interventional radiologist. The approach to the management of an MPE should be individualized and adapted to changing circumstances. Although thrombolytic therapy is considered to be (relatively) contraindicated, successful outcomes with the use of thrombolytic therapy during labor have been reported [15, 16]. We report the case of a 26-year-old pregnant (at 24 weeks) woman with MPE who was successfully treated with thrombolysis. We used rTPA because this fibrinolytic agent does not cross the placental barrier. We recognize that thrombolysis can be dangerous in the early phases of pregnancy, but the urgency of the case required a quick decision. In addition, we also showed that the echocardiogram and clinical and laboratory parameters were invaluable tools to reach a rapid corrected diagnosis, allowing us also to follow the effects of treatment. This choice avoided using possibly dangerous radiant imaging tools on the fetus. In addition, according to ESC guidelines, in mothers the overall incidence of bleeding is about 8%, usually from the genital tract. This risk does not seem unreasonable compared with the death rate seen in patients with massive PE treated with heparin alone . In conclusion, in a patient with life-threatening PE, thrombolytic therapy should not be withheld solely because of pregnancy, but additional studies need to be performed to further define its use.
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