Pulmonary Embolism In Pregnancy Research Articles

Pulmonary Embolism in Pregnancy: A Review for Clinical Practitioners.

Diagnostic and therapeutic decision-making in pregnancy with suspected pulmonary embolism (PE) is challenging. European and other international professional societies have proposed various recommendations that are ambiguous, probably due to the unavailability of randomized controlled trials. In the following sections, we discuss the supporting diagnostic steps and treatments. We suggest a standardized diagnostic work-up in pregnant patients presenting with symptoms of PE to make evidence-based diagnostic and therapeutic decisions. We strongly recommend that clinical decisions on treatment in pregnant patients with intermediate- or high-risk pulmonary embolism should include a multidisciplinary team approach involving emergency physicians, pulmonologists, angiologist, cardiologists, thoracic and/or cardiovascular surgeons, radiologists, and obstetricians to choose a tailored management option including an interventional treatment. It is important to be aware of the differences among guidelines and to assess each case individually, considering the specific views of the different specialties. This review summarizes key concepts of the diagnostics and acute management of pregnant women with suspected PE that are supportive for the clinician on duty.

Validating the safety of low-dose CTPA in pregnancy: results from the OPTICA (Optimised CT Pulmonary Angiography in Pregnancy) Study.

Pulmonary embolism (PE) is a leading cause of pregnancy-related mortality. CT pulmonary angiogram (CTPA) is the first-line advanced imaging modality for suspected PE in pregnancy at institutes offering low-dose techniques; however, a protocol balancing safety with low dose remains undefined. The wide range of CTPA doses reported in pregnancy suggests a lack of confidence in implementing low-dose techniques in this group. To define and validate the safety, radiation dose and image quality of a low-dose CTPA protocol optimised for pregnancy. The OPTICA study is a prospective observational study. Pregnant study participants with suspected PE underwent the same CTPA protocol between May 2018 and February 2022. The primary outcome, CTPA safety, was judged by the reference standard; the 3-month incidence of venous thromboembolism (VTE) in study participants with a negative index CTPA. Secondary outcomes defined radiation dose and image quality. Absorbed breast, maternal effective and fetal doses were estimated by Monte-Carlo simulation on gestation-matched phantoms. Image quality was assessed by signal-to-noise and contrast-to-noise ratios and a Likert score for pulmonary arterial enhancement. A total of 116 CTPAs were performed in 113 pregnant women of which 16 CTPAs were excluded. PE was diagnosed on 1 CTPA and out-ruled in 99. The incidence of recurrent symptomatic VTE was 0.0% (one-sided 95% CI, 2.66%) at follow-up. The mean absorbed breast dose was 2.9 ± 2.1mGy, uterine/fetal dose was 0.1 ± 0.2mGy and maternal effective dose was 1.4 ± 0.9mSv. Signal-to-noise ratio (SNR) was 11.9 ± 3.7. Contrast-to-noise ratio (CNR) was 10.4 ± 3.5. The OPTICA CTPA protocol safely excluded PE in pregnant women across all trimesters, with low fetal and maternal radiation. OPTICA (Optimised CT Pulmonary Angiography in Pregnancy) is the first prospective study to define the achievable radiation dose, image-quality and safety of a low-dose CT pulmonary angiogram protocol optimised for pregnancy (NCT04179487). It provides the current benchmark for safe and achievable CT pulmonary angiogram doses in the pregnant population. • Despite the increased use of CT pulmonary angiogram in pregnancy, an optimised low-dose protocol has not been defined and reported doses in pregnancy continue to vary widely. • The OPTICA (Optimised CT Pulmonary Angiography in Pregnancy) study prospectively defines the achievable dose, image quality and safety of a low-dose CT pulmonary angiogram protocol using widely available technology. • OPTICA provides a benchmark for safe and achievable CT pulmonary angiogram doses in the pregnant population.

Ten-Year Trend in Advanced Imaging Utilization for Suspected Pulmonary Embolism in Pregnancy

PurposeAdvanced imaging is essential to diagnose pulmonary embolism (PE) in pregnancy, but there are associated maternal and fetal radiation risks. The purpose of this study was to evaluate the 10-year trend in advanced imaging utilization for the evaluation of suspected PE in pregnancy. MethodsThe authors evaluated pregnant women with advanced imaging using CT pulmonary angiography (CTPA) or lung scintigraphy (LS) for evaluation of suspected PE presenting to two tertiary hospitals from 2007 to 2016. The rate of imaging was evaluated relative to positive PE rate and local pregnancy rate. positive PE was defined as a new acute PE finding on any advanced imaging within 3 days of first advanced imaging test. Local pregnancy rates were defined per 1,000 pregnancies in the county serviced by both hospitals. Chi-square testing was used to evaluate statistical significance (P < .05) in the utilization trend of advanced imaging and relative to local pregnancy rates and evaluations positive for PE. ResultsA total of 707 pregnant patients were identified, of whom 92.5% (n = 654) underwent CTPA and 7.5% (n = 53) underwent LS. Regression analysis showed an average increase of 5.2 advanced imaging studies per year (P < .001), with 61 and 105 studies performed in 2007 and 2016, respectively. Additionally, there was an average increase of 0.08 (P < .001) advanced imaging studies per 1,000 local pregnancies per year, doubling from 0.7 in 2007 to 1.4 in 2016 (P < .001). Finally, there was a decrease of 0.004 (P = .009) in advanced imaging positive for PE, from 3% (2 of 61) in 2007 to 0% (0 of 100) in 2016. ConclusionsAdvanced imaging utilization increased by 72% over the 10-year window, driven by higher use of CTPA. Although the detection rate of PE on advanced imaging has decreased, the utilization rate among pregnant patients doubled during this period. These results highlight the need to consider the radiation risks and costs of advanced imaging in specific patient populations.

An audit of CTPA and V/Q scan for investigation of pulmonary embolism in pregnancy.

Pulmonary embolism (PE) can be fatal yet difficult to diagnose in pregnancy. Computed tomography pulmonary angiogram (CTPA) or ventilation/perfusion (V/Q) scans are often conducted, potentially leading to low positive scan rates. Retrospective data analysis was conducted for pregnant women and non-pregnant age-matched control who underwent CTPA and/or V/Q scan for investigation of PE. The main outcomes were the positive and non-diagnostic imaging rates. In total, 440 women underwent V/Q or CTPA scans, 86 of whom were pregnant (19.5%). The positive scan rate was 3.5% and 8.8% in the pregnant and non-pregnant groups, respectively (p = 0.1). The non-diagnostic scan rate was similar between pregnant and non-pregnant groups (13.9% vs 9.9%, p = 0.3). Within the pregnant group, there were more non-diagnostic CTPAs than V/Q scans (p = 0.005). Our study confirms a low positive imaging rate and a relatively high non-diagnostic CTPA rate in pregnancy. Newer strategies are needed to reduce the number of negative imaging studies conducted.

Diagnosis of Pulmonary Embolism in Pregnancy.

Pulmonary embolism (PE) is a significant cause of obstetric morbidity and mortality. However, overdiagnosis related to excessive use of diagnostic testing is also associated with long-term major health issues, including impact on future pregnancies and subsequent health care. Accurate diagnosis of PE depends on the knowledge of prevalence of PE in the pregnant population, the a priori probability of a PE based on specific findings in a given patient, and understanding of the accuracy of computed tomography pulmonary angiography (CTPA), the dominant diagnostic modality employed for this diagnosis. Venous thromboembolism is widely considered to be more common in pregnancy. However, this term includes both deep venous thrombosis as well as PE. While the former appears to be more common, published data on the prevalence of PE in pregnancy show little or no increase relative to the general population. Given the published data on the sensitivity and specificity of CTPA, a positive reading is more likely to be a false positive unless the probability of a PE in a given patient is at least 5% (a 200-fold increase from baseline). Doubling the probability to 10% (a 400-fold increase) only improves the positive predictive value to approximately 67%. Strategies to refine the a priori probability of a PE in a given patient are detailed, including scoring systems and D-dimer measurements. A careful history and physical examination and thoughtful development of a differential diagnosis are key elements of clinical practice and should include both the likelihood of each possible diagnosis and the accuracy of diagnostic modalities. This approach should precede the application of a given algorithm. Such a structured approach can decrease utilization and limit false positive diagnoses without increasing morbidity or mortality. KEY POINTS: · Incidence of PE is lower than assumed.. · Incidence is critical for assessing predictive value of a test.. · Computed tomography angiography is likely overused in pregnancy.. · Clinical scoring and D-dimer have a role in PE diagnosis..

Venous Thromboembolism Management in Pregnant Patients

Pulmonary embolism (PE) in pregnancy accounts for 10% of maternal deaths in the United States. As maternal morbidity and mortality continue to increase, it is imperative for all specialties interfacing with pregnant patients to understand the current research and guidelines surrounding risk stratification, diagnosis, and treatments of PE in pregnancy. Given the complexity of high-risk pregnancy-associated PE (PA-PE), that is, which is associated with hemodynamic instability or collapse, and the rising popularity of new technologies to treat high-risk PA-PE in the nonpregnant population, this review aims to emphasize the differences in diagnosis, risk stratification, and management of the pregnant and nonpregnant PE patients. Furthermore, this review will cover treatment paradigms that include anticoagulation versus advanced therapies such as systemic thrombolysis, surgical embolectomy, extracorporeal membrane oxygenation, and inferior vena cava disruption as well as the more novel therapies which fall under the umbrella term of catheter-based treatments. Finally, this review will include a case-based review of 2 patients with PA-PE requiring catheter-based therapies and their ultimate clinical outcomes.

Cardiac Arrest Due to out-of-Hospital Pulmonary Embolism During Pregnancy: Successful Thrombolysis.

Pulmonary embolism (PE) is a rare, severe complication in pregnancy, in which case thrombolysis can be lifesaving but has risks. We aim to highlight actions specific to pregnant women. A 24-week pregnant woman developed shortness of breath and experienced sudden cardiac arrest. Cardiopulmonary resuscitation (CPR) was begun immediately in the ambulance and a perimortem caesarean section was performed upon arrival at hospital, but the new-born died. After 55 minutes of CPR, bedside echocardiography revealed right ventricular strain and thrombolysis was given. The uterus was bandaged to minimize blood loss. After massive transfusions and correction of haemostasis, a hysterectomy was performed due to inability of the uterus to contract. After 3 weeks, the patient was discharged in good health and placed on continuous anticoagulant treatment with warfarin. Approximately 3% of all out-of-hospital cardiac arrest cases are due to PE. Among the few patients who survive at the scene, thrombolysis can be lifesaving and should be considered in pregnant women with unstable PE. Prompt collaborative diagnostic work-up in the emergency room is necessary. In a pregnant woman with cardiac arrest, a perimortem caesarean section improves the chances of both maternal and fetal survival. Thrombolysis should be considered for patients with PE in pregnancy with the same indications as in a non-pregnant woman. In case of survival, there is profuse bleeding with need for massive transfusions and haemostasis correction. Despite being in very poor condition, the above patient survived and was fully restored to health. In a young person with a non-shockable rhythm, pulmonary embolism should be kept in mind, especially if they have risk factors for thromboembolism, and pregnant women should be thrombolysed on the same indication as non-pregnant women.In cardiac arrest, a perimortem caesarean section improves the chances of both maternal and fetal survival, but after major surgery one should be prepared for the need for massive transfusions after thrombolysis. Bandaging the uterus might minimize bleeding. Despite 1-hour cardiac arrest with CPR, the patient survived and made a complete recovery.Lifestyle advice with exercise and sun exposure might help avoid rethrombosis and depression in both the short and long term.

Patient and Fetal Radiation-Induced Malignancy Risk From Imaging For Evaluation of Pulmonary Embolism in Pregnancy

BackgroundImaging for diagnosis of suspected pulmonary embolism in pregnancy presents radiation concerns for patient and fetus. ObjectivesEstimate the risks of radiation-induced breast cancer and childhood leukemia from common imaging techniques for the evaluation of suspected pulmonary embolism in pregnancy. MethodsBreast and uterine absorbed doses for various imaging techniques were input into the National Cancer Institute Radiation Risk Assessment Tool to calculate risk of breast cancer for the patient and childhood leukemia for the fetus. Absorbed doses were obtained by synthesizing data from a recent systematic review and the International Commission on Radiological Protection. Primary outcomes were the estimated excess incidences of breast cancer and childhood leukemia per 100,000 exposures. ResultsBaseline incidences of breast cancer for a 30-year-old woman and childhood leukemia for a male fetus were 13,341 and 939, respectively. Excess incidences of breast cancer were 0.003 and 0.275 for a single and two-view chest radiograph, respectively, 9.53 and 20.6 for low- and full-dose computed tomography pulmonary angiography (CTPA), respectively, 0.616 and 2.54 for low- and full-dose perfusion scan, respectively, and 0.732 and 2.66 for low- and full-dose ventilation perfusion scan, respectively. Excess incidences of childhood leukemia were 0.004 and 0.007 for a single and two-view chest radiograph, respectively, 0.069 and 0.490 for low- and full-dose CTPA, respectively, 0.359 and 1.47 for low- and full-dose perfusion scan, respectively, and 0.856 and 1.97 for low- and full-dose ventilation perfusion scan, respectively. ConclusionExcess cancer risks for all techniques were small relative to baseline cancer risks, with CTPA techniques carrying slightly higher risk of breast cancer for the patient and ventilation perfusion techniques a higher risk of childhood leukemia.

Pulmonary embolism in pregnancy and the puerperium.

Pulmonary embolism (PE) in pregnant women appears to be increasing. This could be related in part to improved health care allowing more women with risk factors to conceive, as well as increase in the high-risk groups which include pregnancies conceived on artificial reproductive technology, advancing maternal age, obesity, and caesarean deliveries. Prevention and early diagnosis with prompt effective treatment can reduce maternal mortality and improve pregnancy outcome, so that obstetricians should be on the lookout for venous thrombosis and PE, especially when in the majority of cases, risk factors only start to emerge or develop in the course of pregnancy and delivery. Management includes accurate diagnosis with ventilation/perfusion scan and CT pulmonary angiography, followed by effective anticoagulation and more aggressive measures such as thrombolysis as indicated, together with general supportive measures. Postpartum management should cover subsequent health issues, including breastfeeding, contraception, mood changes, and recurrence in subsequent pregnancies.

Utilization of a Guideline-recommended Imaging Paradigm for Pregnant Patients With Suspicion of Pulmonary Embolism.

A dose reduction imaging paradigm utilizing chest x-ray (CXR) to triage between computed tomography pulmonary angiography (CTPA) and lung scintigraphy (LS) was introduced in 2001 and adopted in 2012 by the American Thoracic Society/Society of Thoracic Radiology (ATS) guideline for the evaluation of pulmonary embolism in pregnancy. We aimed to assess the utilization of this imaging paradigm preadoption and postadoption by the ATS guideline, and identify factors associated with its utilization. This retrospective cohort study evaluated consecutive pregnant patients who received CTPA or LS for the evaluation of pulmonary embolism in pregnancy at 2 tertiary hospitals between September 2008 and March 2017, excluding 2012 for guideline release washout. Utilization of the imaging paradigm was defined per patient by the use of CXR before advanced imaging, with CTPA performed following positive CXR and LS performed following negative CXR. Multivariate analyses were performed to assess factors associated with utilization of the imaging paradigm. P <0.05 is considered significant. Overall, 9.8% (63/643) of studies utilized the dose reduction imaging paradigm, 13.3% (34/256) before the guidelines, and 7.5% (29/387) after. Multivariable analysis showed that the dose reduction imaging paradigm utilization was higher for inpatients (odds ratio [OR]: 4.5) and outpatients (OR: 3.1) relative to the emergency department patients, and lower for second (OR: 0.3) and third (OR: 0.2) trimester patients, without significant differences by study priority, patient age, or patient race. Guideline-recommended dose reduction imaging paradigm utilization was low, and decreased after guideline publication. Utilization varied by patient setting and trimester, which are potential targets for interventions to improve guideline compliance.

Incidence and outcomes of acute high-risk chest pain diseases during pregnancy and puerperium.

AimTo investigate the incidence and outcomes of acute high-risk chest pain diseases, including acute myocardial infarction (AMI), aortic dissection (AD), and pulmonary embolism (PE) during pregnancy and puerperium.MethodsThe National Inpatient Sample was queried to identify pregnancy-related hospitalizations from January 1, 2008 to December 31, 2017. Temporal trends in the incidence and mortality of AMI, AD and PE were extracted.ResultsAmong 41,174,101 hospitalizations, acute high-risk chest pain diseases were diagnosed in 40,285 (0.098%). The incidence increased from 79.92/100,000 in 2008 to 114.79/100,000 in 2017 (Ptrend < 0.0001). The most frequent was PE (86.5%), followed by AMI (9.6%) and AD (3.3%). The incidence of PE in pregnancy decreased after 2014 and was lower than AMI and AD, while its incidence in puerperium was higher than AMI and AD consistently (Ptrend < 0.0001). Subgroup analysis showed the incidence of these diseases was higher in black women, lowest-income households, and elderly parturients (Ptrend < 0.0001). The mortality decreased from 2.24% in 2008 to 2.21% in 2017 (Ptrend = 0.0240), exhibiting 200-fold higher than patients without these diseases. The following factors were significantly associated with these diseases: aged ≥ 45 years (OR, 4.25; 95%CI, 3.80–4.75), valvular disease (OR, 10.20; 95%CI, 9.73–10.70), and metastatic cancer (OR, 9.75; 95%CI, 7.78–12.22). The trend of elderly parturients increased from 14.94% in 2008 to 17.81% in 2017 (Ptrend < 0.0001), while no such up-trend was found in valvular disease and metastatic cancer.ConclusionThe incidence of acute high-risk chest pain diseases, especially PE in puerperium, increased consistently. Although mortality has shown a downward trend, it is still at a high level. We should strengthen monitoring and management of acute high-risk pain diseases in pregnancy and puerperium, especially for black women, lowest-income households, and elderly parturients in the future.

Pulmonary Embolism in Pregnancy.

Pulmonary embolism during and after pregnancy remains a significant contributor to maternal morbidity and mortality. Symptoms that would be a clear indicator of a pulmonary embolus in the nonpregnant population can be masked by pregnancy and its routine pregnancy-related symptoms. To affect a reduction in this severe maternal mortality indicator, physicians need to maintain a high degree of suspicion coupled with expedient testing.

The Risk of Thrombosis Around Pregnancy: Where Do We Stand?

Pregnancy and puerperium increase the relative risk of venous thromboembolism (VTE) and the absolute risk remains low, around 1 per 1,000, with induced mortality of around 1 per 100,000. Analysis of large databases has helped specify the modes of presentation and risk factors (RF) whose impact is greater after than before childbirth, since VTE during pregnancy and post-partum obey different RFs. The evolution of the population concerned (mostly women over 35, obese, of multi-ethnicity undergoing medically assisted reproduction) affects the frequency of these RFs. Pulmonary embolism (PE) is over-represented after childbirth, but 30% of PE in pregnancy occurs without any RFs. Recommendations for prevention, mainly from expert groups, are heterogeneous and often discordant. Low molecular weight heparins (LMWH) are the mainstay of pharmacological thromboprophylaxis, in a field where randomized controlled studies are definitely lacking. VTE risk assessment in pregnancy must be systematic and repetitive. Risk assessment methods and scores are beginning to emerge to guide thromboprophylaxis and should be used more systematically. In the future, analyzing observational data from huge, nationwide registries and prospective cluster clinical trials may bring to light clinically relevant outcomes likely to feed comprehensive guidelines.

Comparison of Guidelines for Evaluation of Suspected Pulmonary Embolism in Pregnancy: A Cost-effectiveness Analysis

Pulmonary embolism (PE) remains a leading cause of maternal mortality, yet diagnosis remains challenging. International diagnostic guidelines vary significantly in their recommendations, making it difficult to determine an optimal policy for evaluation. Which societal-level diagnostic guidelines for evaluation of suspected PE in pregnancy are an optimal policy in terms of its cost-effectiveness? We constructed a complex Markov decision model to evaluate the cost-effectiveness of each identified societal guidelines for diagnosis of PE in pregnancy. Our model accounted for risk stratification, empiric treatment, diagnostic testing strategies, as well as short- and long-term effects from PE, treatment with low-molecular-weight heparin, and radiation exposure from advanced imaging. We considered clinical and cost outcomes of each guideline from a US health care system perspective with a lifetime horizon. Clinical effectiveness and costs were measured in time-discounted quality-adjusted life years (QALYs) and US dollars, respectively. Strategies were compared using the incremental cost-effectiveness ratio (ICER) with a willingness-to-pay threshold of $100,000/QALY. One-way, multiway, and probabilistic sensitivity analyses were performed. We identified six international societal-level guidelines. Base-case analysis showed the guideline proposed by the American Thoracic Society and Society of Thoracic Radiology (ATS-STR) yielded the highest health benefits (22.90 QALYs) and was cost-effective, with an ICER of $7,808 over the guidelines proposed by the Australian Society of Thrombosis and Haemostasis and the Society of Obstetric Medicine of Australia and New Zealand (ASTH-SOMANZ). All remaining guidelines were dominated. The ATS-STR guideline-recommended strategy yielded an expected additional 2.7 QALYs/100 patients evaluated over the ASTH-SOMANZ. Conclusions were robust to sensitivity analyses, with the ATS-STR guidelines optimal in 86%of probabilistic sensitivity analysis scenarios. The ATS-STR guidelines for diagnosis of suspected PE in pregnancy are cost-effective and generate better expected health outcomes than guidelines proposed by other medical societies.

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

Update on pulmonary embolism in pregnancy and post-partum: The Society of Obstetric Medicine of Australia and New Zealand Position Statement on Pulmonary Embolism in Pregnancy and Post-partum.

In this clinical review we highlight aspects of the diagnosis and management of pulmonary embolism (PE) in pregnancy and post-partum and how this may impact on antenatal and postnatal management. Investigation for PE in pregnancy is challenging and includes appropriate patient selection and knowledge of the risks and benefits of pulmonary imaging modalities. The complete Society of Obstetric Medicine of Australia and New Zealand Position Statement on Pulmonary Embolism in Pregnancy and Post-Partum comprehensively reviews all aspects of diagnosis, investigation and management and is accessible at https://www.somanz.org/guidelines.asp. It includes a summary of all recommendations and a guide to developing a management plan for birth in women on anticoagulation.

Pulmonary Embolism in Pregnancy: Ultrasound-Assisted Catheter-Directed Thrombolytic Therapy for the Treatment of a Pulmonary Embolus—A Case Report

Abstract In the United States, pulmonary embolism (PE) accounts for approximately 10% of all pregnancy related deaths. The standard treatment for a patient with high-risk PE is systemic thrombolysis. Systemic thrombolysis in pregnancy is associated with the risk of maternal hemorrhage and fetal complications, including spontaneous abortion, preterm delivery, and fetal bleeding. Currently, there is limited evidence for a standardized approach for the treatment and management of intermediate- and high-risk PEs in pregnancy. A 36-year-old gravida 3 para 2002 woman at 31+1 weeks of gestation with a history of deep vein thrombosis in her prior pregnancy presented with shortness of breath. A computed tomography angiogram revealed a large pulmonary embolus with a saddle component that extended into the bilateral upper and lower lobes and into the secondary and tertiary pulmonary branches. A subsequent bedside echocardiogram demonstrated a dilated right ventricle with severely reduced right ventricular systolic function. The patient was successfully treated with bilateral ultrasound-assisted catheter-directed thrombolysis. She subsequently delivered a healthy male infant at term. Reported cases of ultrasound-assisted catheter-directed thrombolysis in pregnant patients is limited. Our case demonstrates that localized thrombolysis is a viable treatment option for life-threatening PE in pregnancy. Catheter-directed thrombolysis can be efficacious in treating intermediate- and high-risk PEs in pregnancy while simultaneously reducing the risk of bleeding complications.

What to Do When They’re Eating for Two? A Case of Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism in Pregnancy

ABSTRACTA 33-year-old G7P0 female at 8 weeks gestation presented to the emergency department (ED) following a syncopal episode. She complained of chest pain and dyspnea, and had hemodynamic instability, which responded to intravenous fluids. Continued fluid resuscitation, supplemental oxygen, as well as therapeutic dose low molecular weight heparin (LMWH) were administered in the ED. Computed tomography (CT) pulmonary angiogram confirmed saddle pulmonary embolism (PE). After 12 h of continued chest pain and high oxygen requirements, a decision was made to use catheter-directed thrombolysis (CDT) involving alteplase with manual thrombus maceration in bilateral pulmonary arteries. There were no immediate hemorrhagic complications and follow-up fetal ultrasound demonstrated a normal viable intrauterine pregnancy. She clinically improved and was discharged on LMWH. Cesarean section was scheduled, and the patient delivered a healthy term infant at 37 weeks gestation without complications. Our case demonstrates that CDT may be a safe and effective treatment for submassive PE in pregnancy. RÉSUMÉUne femme âgée de 33 ans et enceinte de huit semaines (G7P0) se présente aux urgences à la suite d’un épisode syncopal. Elle se plaint de douleurs thoraciques et de dyspnée et présente une instabilité hémodynamique qui répond aux solutés intraveineux. Une réanimation liquidienne continue, une oxygénothérapie ainsi qu’une dose thérapeutique d’héparine de faible poids moléculaire sont administrées aux urgences. L’angiographie pulmonaire par tomodensitométrie confirme une embolie pulmonaire en selle. Après 12 heures de douleurs thoraciques continues et de besoins élevés en oxygène, on décide d’utiliser la thrombolyse dirigée par cathéter (TDC) à l’aide de l’altéplase avec macération manuelle du thrombus dans les artères pulmonaires bilatérales. Il n’y a pas eu de complications hémorragiques immédiates et le suivi échographique du fœtus a démontré une grossesse intra utérine normale et viable. Son état clinique s’est amélioré et elle a obtenu son congé sous héparine de faible poids moléculaire. Une césarienne a été planifiée et la patiente a accouché d’un enfant à terme et en bonne santé à 37 semaines de grossesse, sans complications. Notre cas démontre que la TDC peut être un traitement sûr et efficace de l’embolie pulmonaire submassive en cours de grossesse.

Pulmonary Embolism in Pregnancy.

Even though venous thromboembolism is a leading cause of maternal mortality in high-income countries, there are limited high-quality data to assist clinicians with the management of pulmonary embolism in this patient population. Diagnosis, prevention, and treatment of pregnancy-associated pulmonary embolism are complicated by the need to consider fetal, as well as maternal, well-being. Recent studies suggest that clinical prediction rules and D-dimer testing can reduce the need for diagnostic imaging in a subset of patients. Low-molecular-weight heparin is the preferred anticoagulant for both prophylaxis and treatment in this setting. Direct oral anticoagulants are contraindicated during pregnancy and in breastfeeding women. Thrombolysis or embolectomy should be considered for pregnant women with pulmonary embolism complicated by hemodynamic instability. Treatment of pregnancy-associated pulmonary embolism should be continued for at least 3 months, including 6 weeks postpartum. Management of anticoagulants at the time of delivery should involve a multidisciplinary individualized approach that uses shared decision making to take patient and caregiver values and preferences into account.