Thrombolysis for Massive Pulmonary Embolism in Pregnancy

Abstract

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.

How I treat venous thromboembolism in pregnancy

“…In a literature review, 23 cases involving the use of systemic thrombolysis in pregnancy for massive PE were identified. 45 There were no maternal deaths, and bleeding complications were reported in 39% of the cases. Bleeding was classified as major in 22% of women, 9% of the fetuses died, and 39% of pregnancies resulted in preterm delivery.…”

Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism in the Third Trimester of Pregnancy

“…There is currently no consensus surrounding the use of systemic or catheter direct thrombolysis as a primary treatment for patients who present with a submassive PE, due to controversy regarding risk-benefit ratio. Compared to systemic thrombolysis, CDT has the potential to lower the risk of bleeding by localizing drug delivery directly to the area of interest, allowing for a two-thirds reduction in the required dose ( 7 ). Numerous studies have demonstrated the efficacy and safety of CDT for PE in the general population.…”

“…The primary concern for this patient was that without thrombolysis, cardiac dysfunction would worsen with ongoing pregnancy, with the potential for catastrophic urgent preterm delivery or decompensation during term delivery. CDT was chosen over systemic thrombolysis to minimize the dose of tissue plasminogen activator, given concerns regarding risk of bleeding and possible fetal effects ( 7 ).…”

Contemporary best practice in the management of pulmonary embolism during pregnancy

“…A recent literature review summarized 23 case reports on the use of systematic thrombolysis as treatment for massive PE in pregnant patients. 55 No maternal deaths occurred, and fetal deaths were reported in 2 of 23 (9%) cases. Bleeding complications were reported in 9 of 23 (39%) cases of which 5 of 23 (22%) were major bleeding.…”