Thrombolysis in massive and submassive pulmonary embolism during pregnancy and the puerperium: a systematic review

Rodríguez, David; Jerjes‐Sánchez, Carlos; Fonseca, S; Garcia-Toto, Rebeca; Martinez-Alvarado, Jhon; Panneflek, Jathniel; Ortiz-Ledesma, Claudia

doi:10.1007/s11239-020-02122-7

Cited by 24 publications

(17 citation statements)

References 77 publications

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“…In PA-VTE the use of biomarkers and echocardiography was low as observed in recent evidence. 35 Women with PA-VTE were more likely to be initiated on parenteral therapy, typically LMWH, reflecting guideline recommendations. 11,13,34,36 The safety and efficacy of LMWHs for the treatment of VTE in pregnancy have been shown previously, 37 as they do not cross the placenta and are associated with fewer adverse effects than unfractionated heparin.…”

Section: Discussionmentioning

confidence: 97%

Pregnancy-Associated Venous Thromboembolism: Insights from GARFIELD-VTE

Jerjes‐Sánchez

Rodríguez

Farjat

et al. 2021

TH Open

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Introduction The risk of venous thromboembolism (VTE) increases during pregnancy and the puerperium such that VTE is a leading cause of maternal mortality. Methods We describe the clinical characteristics, diagnostic strategies, treatment patterns, and outcomes of women with pregnancy-associated VTE (PA-VTE) enrolled in the Global Anticoagulant Registry in the FIELD (GARFIELD)-VTE. Women of childbearing age (<45 years) were stratified into those with PA-VTE (n = 183), which included pregnant patients and those within the puerperium, and those with nonpregnancy associated VTE (NPA-VTE; n = 1,187). Patients with PA-VTE were not stratified based upon the stage of pregnancy or puerperium. Results Women with PA-VTE were younger (30.5 vs. 34.8 years), less likely to have pulmonary embolism (PE) (19.7 vs. 32.3%) and more likely to have left-sided deep vein thrombosis (DVT) (73.9 vs. 54.8%) compared with those with NPA-VTE. The most common risk factors in PA-VTE patients were hospitalization (10.4%), previous surgery (10.4%), and family history of VTE (9.3%). DVT was typically diagnosed by compression ultrasonography (98.7%) and PE by chest computed tomography (75.0%). PA-VTE patients more often received parenteral (43.2 vs. 15.1%) or vitamin K antagonists (VKA) (9.3 vs. 7.6%) therapy alone. NPA-VTE patients more often received a DOAC alone (30.2 vs. 13.7%). The risk (hazard ratio [95% confidence interval]) of all-cause mortality (0.59 [0.18–1.98]), recurrent VTE (0.82 [0.34–1.94]), and major bleeding (1.13 [0.33–3.90]) were comparable between PA-VTE and NPA-VTE patients. Uterine bleeding was the most common complication in both groups. Conclusion VKAs or DOACs are widely used for treatment of PA-VTE despite limited evidence for their use in this population. Rates of clinical outcomes were comparable between groups.

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Section: Discussionmentioning

confidence: 97%

Pregnancy-Associated Venous Thromboembolism: Insights from GARFIELD-VTE

Jerjes‐Sánchez

Rodríguez

Farjat

et al. 2021

TH Open

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“…Oxygen desaturation is rare as a presenting sign and often associated with a large saddle embolism. Recommendations are that any woman presenting in pregnancy or the postpartum period with symptoms suggestive of pulmonary embolism should receive the appropriate imaging if hemodynamically stable [8][9][10]. First, a chest X-ray should be obtained.…”

Section: Discussionmentioning

confidence: 99%

“…First, a chest X-ray should be obtained. If results of the Xray are normal, then a ventilation perfusion (V/Q) scan should be obtained next [8][9][10]. If chest X-ray is found to be abnormal, follow-up imaging should be a computed tomography pulmonary angiography [8][9][10].…”

Section: Discussionmentioning

confidence: 99%

“…If results of the Xray are normal, then a ventilation perfusion (V/Q) scan should be obtained next [8][9][10]. If chest X-ray is found to be abnormal, follow-up imaging should be a computed tomography pulmonary angiography [8][9][10]. Figure 4 demonstrates the basic algorithm for diagnosing pulmonary embolism in pregnancy and the postpartum period in a Case Reports in Obstetrics and Gynecology hemodynamically stable and unstable patient.…”

Section: Discussionmentioning

confidence: 99%

“…Figure 4 demonstrates the basic algorithm for diagnosing pulmonary embolism in pregnancy and the postpartum period in a Case Reports in Obstetrics and Gynecology hemodynamically stable and unstable patient. In cases of unstable hemodynamic status, the patient should be started on therapeutic anticoagulation therapy prior to diagnostic modalities [8][9][10]. A bedside echocardiogram may also aid in quick diagnosis by demonstrating changes associated with right-sided heart strain (dilated right atrium/right ventricle) if computed tomography pulmonary angiography is not immediately available [8,9].…”

Section: Discussionmentioning

confidence: 99%

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Systemic Thrombolysis for Treatment of Postpartum Saddle Embolism Complicated by Postpartum Hemorrhage: A Case Report and Brief Literature Review

Mostajeran¹,

Boswell²,

Haidar³

2021

Case Reports in Obstetrics and Gynecology

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Venous thromboembolic events (VTE), specifically pulmonary embolisms, account for a significant portion of maternal morbidity and mortality. Due to the procoagulant physiological changes that occur, pregnancy and the postpartum period are known risk factors for thromboembolic events. The risk is greatest during the first-week postpartum and remains elevated for up to six weeks as compared to the general population. Treatment guidelines regarding the use of thrombolytics for massive pulmonary embolism occurring in pregnancy and the postpartum are not well established. In nonpregnant populations, thrombolytic agents are well known to decrease the mortality in the setting of a massive pulmonary embolism. However, in the absence of management guidelines, thrombolysis in pregnancy remains guided by case reports and case series. We present a case of a massive pulmonary embolism (PE) causing hemodynamic instability during the postpartum period treated with tissue plasminogen activator (tPA). The case was complicated by delayed postpartum hemorrhage successfully managed with the uterotonic methylergometrine. The patient was started on oral anticoagulation and continued for six months without recurrent VTE. Our case demonstrates a rare occurrence of a saddle embolism after a vaginal delivery within the first postpartum week which was successfully managed with the use of systemic thrombolysis and minimal intervention to manage the iatrogenic delayed postpartum hemorrhage. To the authors’ knowledge, no other similar case report exists. This case highlights the need to develop guidelines for the use of thrombolysis in mothers who present with massive pulmonary embolus and a noninvasive means to manage adverse bleeding events in the puerperium.

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