The use of thrombolytic therapy in pregnancy

Abstract

The relative hypercoagulable state of pregnancy leads to an increased risk of thrombotic complications, of which some may be life-threatening or medically devastating. In the non-pregnant patient, the current guidelines suggest thrombolysis as the primary treatment in acute ischemic stroke, myocardial infarction when percutaneous intervention is unavailable, certain cases of mechanical valve thrombosis, and pulmonary embolism with hemodynamic compromise or shock. Given that clinical trial data regarding thrombolytic use in pregnant women are absent due to exclusion, the goal of this review is to summarize the available published data regarding the use of thrombolytic agents and subsequent outcomes and complications in pregnant women. Overall, the use of thrombolytic agents in pregnancy is associated with a relatively low reported complication rate, especially given the severe medical conditions for which they are indicated. The data would suggest that thrombolysis should be considered for appropriate indications similar to that of non-pregnant patients. However, caution should be exercised when drawing conclusions regarding maternal and fetal safety, given the lack of controlled clinical trials including pregnant women and the nature of the weak evidence level of the cumulative data presented in this review.

Management dilemmas in acute pulmonary embolism

“…If PE is within a month of the expected date of delivery then a retrievable IVC filter should be inserted. A recent review identified 189 pregnant patients receiving thrombolysis for venous thromboembolism (VTE); major bleeding occurred in 2.6% with no maternal mortality 83. The peri-partum period poses a challenge with greater risk of haemorrhage associated with thrombolysis.…”

Thrombolysis for Massive Pulmonary Embolism in Pregnancy

“…Thus it is unlikely that any thrombolytics will reach the fetus directly because they are all larger than 1000 Da. However, agents with larger molecular weights could presumably be preferred because the risk of reaching the fetus would be lowest . No registry exists to monitor pregnancy outcomes in women exposed to thrombolytics.…”

“…Streptokinase undergoes insignificant placental transfer . However, a disadvantage of this agent is that it must be administered over 24 hours . Streptokinase is also associated with antibody development due to its nonspecific plasminogen binding, provoking allergic reactions and hypotension .…”

“…Table summarizes the basic pharmacokinetic characteristics of the thrombolytic agents . The thrombolytics are similar in that pharmacokinetic drug‐drug interactions do not appear to be clinically relevant.…”

Treatment and diagnosis of pulmonary embolism in pregnancy

“…Son yayınlanan Avrupa PE kılavuzunda trombolitik kullanılacak gebelerde doku-plazminojen aktivatörü (tPA) önerilmekte-dir (48). Bu konuda yakın zamanda yapılan bir derlemede 189 gebe hastada VTE için kullanılan trombolitik ilaçların anne mortalitesi artırmadan, %2.6 oranın-da majör kanamaya yol açtığı belirtilmiştir (49). Fare ve tavşan çalışmalarında tPA teratojenik etkisi göste-rilmemiştir (50).…”