394. Thrombolysis for intermediate risk pulmonary embolism in pregnancy

Abstract

Introduction Pulmonary embolism (PE) in pregnancy is a leading cause of maternal death. Due to inherent haemorrhage risk, thrombolysis is reserved as a lifesaving intervention for massive PE. There is current controversy about using thrombolysis in those with intermediate risk (submassive) PE. We present two cases of intermediate risk PE who failed to respond to IV unfractionated heparin (UFH). Case 1 A 34-year-old para 2 without risk factors for venous thromboembolism (VTE), presented at 22 weeks gestation with hypoxia and breathlessness that confined her to bed for over a week. She had multiple bilateral PEs, right ventricular strain on echocardiogram and elevated troponin and BNP. She did not improve with 24hrs IV UFH and so was treated with systemic thrombolysis according to the MOPPETT regime and then converted to low molecular weight heparin (LMWH). She had an uncomplicated vaginal delivery at 36 weeks with no haemorrhage. Case 2 A 28-year-old para 1, low risk for VTE, presented at 31 weeks with dyspnoea worsening over two weeks. She had bilateral main pulmonary artery PEs, echocardiographic right-sided heart strain and increased levels of troponin and BNP. She was admitted for IV UFH, but within 24 h suffered an acute hypotensive episode. She was not delivered; instead she was treated with ultrasound-enhanced catheter-directed thrombolysis (EKOS, BTG Int’l) via catheters placed in the right and left pulmonary arteries. A total dose of 22 mg alteplase was administered over 24hrs. Fibrinogen was monitored and supplemented if Discussion These cases illustrate that thrombolysis for poorly responding intermediate risk and massive PE need not be withheld in pregnancy, delivery need not be expedited, and pregnancy can continue successfully after treatment.