Massive Pulmonary Embolism In Pregnancy Research Articles

Massive Pulmonary Embolism in Pregnancy and Perimortum Caesrean Section

Massive Pulmonary Embolism in Pregnancy and Perimortum Caesrean Section

THE CONUNDRUM OF TREATING SUB-MASSIVE PULMONARY EMBOLISM IN A PREGNANT PATIENT

TOPIC: Pulmonary Vascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pulmonary embolism (PE) is an important cause of morbidity and mortality during pregnancy. 20% of maternal deaths during pregnancy are related to PE. Treatment decisions are further complicated by pregnancy, in which the outcome of the fetus is also at stake. While emerging data support the use of thrombolytic therapy during pregnancy for life-threatening PE, there are no conclusive data on the appropriate treatment (1). CASE PRESENTATION: A 7-week pregnant, 31-year-old women with history of protein C deficiency was admitted for acute onset dyspnea and syncopal episode. On physical examination, the heart rate was 136 bpm and blood pressure was 121/87 mm Hg. Oxygen saturation was 97% on room air. There was no heart murmur, lungs were clear to auscultation, and the extremities appeared normal. Troponin I level was 0.908 ng/mL and Bnp was 115pg/ml. Electrocardiogram showed sinus tachycardia. Computed tomography pulmonary angiography showed large pulmonary emboli involving the distal main pulmonary artery, left and right pulmonary arteries extending into the proximal lobar and segmental arteries bilaterally (Image 1 and 2). Echocardiogram showed a dilated right ventricle with free wall hypokinesia and displacement of the interventricular septum towards the left ventricle. Multi-disciplinary team meeting was done to discuss the risks and benefits of systemic thrombolysis and catheter-directed thrombolysis. The patient chose catheter-directed thrombolysis and after the procedure, patient's symptoms improved significantly. Due to risk of fetal anomalies from radiation exposure, patient decided to terminate her pregnancy. DISCUSSION: The guidelines on management of life-threatening acute PE in pregnancy is not well established. Teratogenicity due to thrombolytic agent has not been reported, though the risk of maternal hemorrhage is high. Catheter directed thrombolysis reduces the complications encountered in systemic thrombolysis yet require radiation exposure. CTPA and catheter directed thrombolysis usually exposes patient between 50-100mGy of radiation. During the 5th-10th week of gestation, exposures between 50-100Gy have uncertain potential side effects to the fetus. Systemic review of case series and case reports among 172 pregnant females treated with thrombolytic agents, the maternal mortality was 1%, the incidence of fetal loss was 6%, and the incidence of maternal hemorrhagic complications was 8% (2). Limited data is available for catheter directed thrombolytic therapy during 1st trimester of pregnancy, and if deemed necessary, a shared decision making with patient regarding termination of pregnancy should be made (3). CONCLUSIONS: The use of systemic or catheter directed thrombolysis is associated with positive outcomes and relatively low risk of complications. Yet, clinical judgements should be made based on individual patients risks versus benefits. REFERENCE #1: Heavner MS, Zhang M, Bast CE, Parker L, Eyler RF. Thrombolysis for Massive Pulmonary Embolism in Pregnancy. Pharmacotherapy. 2017 Nov;37(11):1449-1457. doi: 10.1002/phar.2025. Epub 2017 Oct 10. REFERENCE #2: Turrentine MA, Braems G, Ramirez MM. Use of thrombolytics for the treatment of thromboembolic disease during pregnancy. Obstet Gynecol Surv. 1995;50(7):534. REFERENCE #3: Bloom AI, Farkas A, Kalish Y. Pharmacomechanical catheter directed thrombolysis for pregnancy related iliofemoral deep vein thrombosis. J Vasc Interv Radiol 2015;26:992-1000. 10.1016/j.jvir.2015.03.001 DISCLOSURES: No relevant relationships by Ki Lee, source=Web Response No relevant relationships by Pratik Patel, source=Web Response No relevant relationships by SHREY SHAH, source=Web Response

CATHETER DIRECTED THROMBOLYSIS FOR MASSIVE PULMONARY EMBOLISM IN A PREGNANT PATIENT

SESSION TITLE: Critical Care 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Pulmonary embolism (PE) is a leading cause of maternal mortality in the United States [1]. CASE PRESENTATION: We report a 27-year-old female at 13 weeks gestation who presented with massive PE and circulatory shock and was successfully treated with catheter directed thrombolysis. History of syncope prior to arrival combined with EKG changes and findings on bedside ultrasound led to a high clinical suspicion for PE with diagnosis confirmed by computed tomography. The patient was admitted to the intensive care unit on systemic anticoagulation with unfractionated heparin. Subsequent circulatory shock led to the decision for catheter directed thrombolytic therapy. The advantage of our treatment choice was rapid clot lysis, return of normal hemodynamics, and avoidance of the risk of complications associated with higher doses of thrombolytic agents [2]. The patient remained hospitalized for 5 days without complication and was discharged on low-molecular weight heparin injections. DISCUSSION: The morbidity and mortality associated with PE during pregnancy demands prompt diagnosis and treatment. In general, thrombolytic agents are relatively contraindicated during pregnancy because of the presumed risk of maternal bleeding and fetal loss. The teratogenicity for these agents in humans is also uncertain [3]. CONCLUSIONS: Ultimately, all life-saving measures must be considered in the face of hemodynamic collapse. Our case demonstrates a positive outcome from catheter directed thrombolytic therapy and contributes to the growing literature in outcomes of treatment in massive PE in pregnancy. Reference #1: 1 Creanga, Andreea A., et al. “Pregnancy-Related Mortality in the United States, 2006-2010.” Obstetrics & Gynecology, vol. 125, no. 1, Jan. 2015, pp. 5–12., https://doi.org/10.1097/aog.0000000000000564. Reference #2: 2 Brandt, Kimberly, et al. “Low-Dose Systemic Alteplase (TPA) for the Treatment of Pulmonary Embolism.” Annals of Pharmacotherapy, vol. 49, no. 7, Sept. 2015, pp. 818–824., https://doi.org/10.1177/1060028015579988. Reference #3: 3 Ahearn GS, Hadjiliadis D, Govert JA, Tapson VF. Massive Pulmonary Embolism During Pregnancy Successfully Treated With Recombinant Tissue Plasminogen ActivatorA Case Report and Review of Treatment Options. Arch Intern Med. 2002;162(11):1221–1227. https://doi.org/10.1001/archinte.162.11.1221 DISCLOSURES: No relevant relationships by daniel goldbach, source=Web Response

Thrombolysis for Massive Pulmonary Embolism in Pregnancy.

Pregnant women are at high risk for venous thromboembolism, including pulmonary embolism (PE), given expected changes in coagulation, fibrinolysis, and venous blood flow. In fact, PE is the leading cause of maternal death in the United States. Nonpregnant patients who develop PE with hypotension or show signs of deterioration after anticoagulation receive thrombolytics as a standard of care. Pregnant women, however, have been excluded from clinical trials with thrombolytics, and all data available in this population are published as case reports or case series. We reviewed all reports of thrombolytics, systemic or catheter directed, used in pregnant patients with massive PE. This article summarizes the risks for thromboembolism in pregnancy, compares and contrasts thrombolytic agents in this setting, and provides a recommendation for management of massive PE in this special population. Overall, reports suggest that the use of these agents is associated with beneficial outcomes and a relatively low risk of complications. The quality of this evidence is low, and clinical judgment is required to assess individual patients for risks versus benefits of thrombolysis.

Случай успешного тромболизиса при массивной тромбоэмболии легочной артерии у беременной

We present a case of successful thrombolysis in massive pulmonary embolism in pregnancy. No severe haemorrhagic complications were observed. Thrombolysis was effective and did not affect the pregnancy and the fetus.

PMM.18 Thrombolysis for massive pulmonary embolism in pregnancy: A case report and literature review

Venous thromboembolism (VTE) remains to be the leading cause of maternal mortality. The management of pulmonary embolus (PE) in pregnancy is complicated by the lack of validated trials. The use...

Thrombolysis for the management of massive pulmonary embolism in pregnancy

Massive pulmonary embolism in pregnancy is a major cause of maternal mortality; the management is challenging, and often requires aggressive therapy. Thrombolysis has been used, often with favorable outcome, but has not been previously reported in a patient presenting with an intrauterine death. We present a 29-year-old nulliparous patient who had a massive pulmonary embolus associated with fetal death in the third trimester of pregnancy. Diagnosis of pulmonary embolus was aided by transthoracic echocardiography and the patient was successfully treated with streptokinase.

Thrombolysis for massive pulmonary embolism in pregnancy: a case report

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.

Thrombolysis for massive pulmonary embolism in pregnancy: a case report

Thrombolysis for massive pulmonary embolism in pregnancy: a case report

Management of a massive pulmonary embolism in a pregnant patient with mechanical fragmentation followed by delayed catheter-directed thrombolysis in the early postpartum period

There are limited data available on the management of massive pulmonary embolism in pregnancy. The use of systemic thrombolysis has been reported, but there are few documented cases on the use of mechanical fragmentation or catheter-directed thrombolysis. Systemic thrombolysis in pregnancy increases the risk of major hemorrhage and there are reports of massive subchorionic hematomas following its use. We describe the use of mechanical fragmentation and optional retrievable inferior vena cava (IVC) filter insertion in a 38-week pregnant woman followed by delayed pharmacological catheter-directed thrombolysis during the early postpartum period to successfully treat a massive pulmonary embolism.

Massive Pulmonary Embolism in Pregnancy Treated with Tissue Plasminogen Activator

Massive Pulmonary Embolism in Pregnancy Treated with Tissue Plasminogen Activator

Massive Pulmonary Embolism in Pregnancy Treated with Catheter Fragmentation and Local Thrombolysis

Massive Pulmonary Embolism in Pregnancy Treated with Catheter Fragmentation and Local Thrombolysis

Massive Pulmonary Embolism in Pregnancy Treated With Tissue Plasminogen Activator

Systemic thrombolysis with tissue plasminogen activator (t-PA) in pregnancy is still considered an experimental treatment. Several reports have described the successful use of t-PA in the setting of hemodynamic instability in gravidas with massive pulmonary emboli. A 34-year-old woman received a diagnosis of severe pulmonary embolism at 23 weeks of gestation. She developed pulmonary hypertension and became hemodynamically unstable. Thrombolytic therapy using t-PA was administered. The patient tolerated thrombolysis well and delivered at term. No placental abnormalities were identified on ultrasonogram or after delivery. The patient was also found to be a heterozygous carrier of prothrombin G20210A mutation. We describe the successful thrombolysis with t-PA of a massive, life-threatening pulmonary embolism without complications followed by a term delivery.

Massive Pulmonary Embolism in Pregnancy Treated With Catheter Fragmentation and Local Thrombolysis

Catheter-directed thromboembolus fragmentation and thrombolysis is used with success for treatment of pulmonary embolism with hemodynamic decompensation in nonpregnant patients, but information on its use during pregnancy is limited. We report successful treatment of massive bilateral pulmonary emboli in the third trimester of pregnancy. A 29-year-old multigravida at 30 weeks of gestation presented with dyspnea, chest pain, heart palpitations, and syncope. A computed tomographic angiogram demonstrated massive bilateral central pulmonary emboli. Despite heparin and oxygen therapy, aggressive fluid resuscitation and pressor treatment, hypotension persisted, and there were prolonged, deep fetal heart rate decelerations. Emergency percutaneous pulmonary artery catheter thrombus fragmentation, followed by local infusion of tissue plasminogen activator, was performed. The patient recovered rapidly and was discharged from the hospital on subcutaneous low-molecular-weight heparin. She was delivered of a normal, healthy infant at term. Catheter-directed mechanical fragmentation and local thrombolytic infusion therapy is a treatment option for pulmonary embolism with hemodynamic decompensation in pregnancy. Advantages are rapid clot lysis with consequent return of normal hemodynamics and uterine perfusion and avoidance of systemic thrombolytics and associated risk of bleeding complications.

Successful urokinase treatment of massive pulmonary embolism in pregnancy

Thrombolytic agents have been used successfully to treat patients with massive pulmonary embolism and cardiorespiratory insufficiency, but experience with these drugs in pregnancy is limited. A 20-year-old woman at 21 weeks' gestation was admitted with a massive pulmonary embolism. She was initially given intravenous heparin therapy but because of worsening clinical condition, urokinase was used. After two 12-hour periods of therapy, the urokinase was discontinued and the heparin restarted. She remained on subcutaneous heparin therapy for the remainder of her pregnancy, which was otherwise uncomplicated. She delivered a healthy male infant at term without complications and was discharged on warfarin therapy. Thrombolytic therapy can be life-saving and should be considered in the treatment of hemodynamically significant pulmonary embolism in pregnancy.