Safe administration of intrapleural alteplase during pregnancy

Abstract

Instillation of intrapleural (IP) fibrinolytics has been used in patients with complicated parapneumonic pleural effusions to improve fluid drainage and decrease the need for surgical intervention. However, clinical trials have not included certain special populations such as pregnant females and there are currently no published case reports of this practice in this group. We describe the case of a 35-year-old female, G2P1 at 32 weeks of gestation, with a complicated pleural effusion due to influenza pneumonia with superimposed bacterial pneumonia. Her parapneumonic pleural effusion was successfully treated with intercostal tube drainage and IP alteplase [tissue plasminogen activator (tPA)] administration and systemic antibiotics with no harm to her or her fetus, sparing this patient from more invasive surgical procedures. This is the first reported case of successful IP tPA administration for a complicated parapneumonic pleural effusion in a pregnant patient.

Keywords: Alteplase; intrapleural; pleural effusion; pregnancy.

Figure 1

Chest radiograph taken prior to IP tPA administration, revealing streaky right lower lobe opacities. tPA, tissue plasminogen activator.

Figure 2

Chest CT scan revealing moderate size right sided pleural effusion (arrow) with underlying right lower lobe compressive atelectasis.

Figure 3

Chest ultrasound pre- and post-IP tPA. (A) Ultrasound of right chest revealing moderate sized right sided pleural effusion (white arrow head), with underlying debris and septations in the pleural space (red arrow); (B) ultrasound of the right chest post-IP tPA therapy revealing no residual pleural effusion. Lung curtain sign revealed (black arrow), obscuring the underlying diaphragm (white arrow). tPA, tissue plasminogen activator.

Figure 4

Chest radiograph post-IP tPA revealing small residual discoid atelectasis in the right lower lobe, with minimal residual right pleural effusion. tPA, tissue plasminogen activator.