Treatment options in massive pulmonary embolism during pregnancy; a case-report and review of literature

Abstract

Systemic thrombolysis with recombinant tissue plasminogen activator (rt-PA), streptokinase or urokinase is considered as high-risk treatment in pregnancy. However, several reports have described the successful use of systemic thrombolysis in pregnant patients with massive pulmonary embolism and haemodynamic instability.

Case: We describe a 34-year old, pregnant female, who presented at 25 weeks of gestation with an acute collapse with reduced consciousness and shortness of breath caused by massive pulmonary embolism. Because of significant haemodynamic instability, increased right ventricular pressure and no improvement after intravenous heparin, thrombolytic therapy was administered. The response to thrombolytic therapy was excellent. No severe haemorrhagic complications were observed. Anticoagulant therapy with LMWH was continued until delivery. A healthy child was born at term.

Review: In English literature, 13 patients received thrombolysis during pregnancy because of pulmonary embolism. No maternal deaths, four non-fatal maternal major bleeding complications, 30.8%;95%CI(9.1-61.4), two fetal deaths, 15.4%;95%CI(1.9-45.5), and five preterm deliveries, 38.5%;95%CI(13.9-68.4), were observed. Surgical embolectomy and catheter embolectomy or catheter thrombolysis has only been performed in 12 patients.

Conclusion: The number of reports on thrombolytic therapy, surgical embolectomy and catheter embolectomy or thrombolysis for massive pulmonary embolism during pregnancy are limited. We suggest an international registry for pregnant patients undergoing thrombolysis or embolectomy to gain more information about these treatment options. Nevertheless, complication rates of thrombolytic therapy are acceptable in the light of the underlying disease, and in the meantime, current data do not justify withholding pregnant women from thrombolytic therapy in case of life-threatening PE.