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Makowska A, Treumann T, Venturini S, Christ M. Pulmonary Embolism in Pregnancy: A Review for Clinical Practitioners. J Clin Med 2024; 13:2863. [PMID: 38792409 PMCID: PMC11121909 DOI: 10.3390/jcm13102863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
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.
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Affiliation(s)
- Agata Makowska
- Emergency Department, Cantonal Hospital Lucerne, 6000 Lucerne, Switzerland; (S.V.); (M.C.)
- Cardiology, Hospital Centre of Biel, 2501 Biel, Switzerland
| | - Thomas Treumann
- Radiology, Cantonal Hospital Lucerne, 6000 Lucerne, Switzerland;
| | - Stefan Venturini
- Emergency Department, Cantonal Hospital Lucerne, 6000 Lucerne, Switzerland; (S.V.); (M.C.)
| | - Michael Christ
- Emergency Department, Cantonal Hospital Lucerne, 6000 Lucerne, Switzerland; (S.V.); (M.C.)
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2
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Truong RD, Cheyney S, Vo M, Garcia J, Desai NN, Kropf J, Hassanein H. Successful Treatment of Massive Pulmonary Embolism in Pregnancy with Catheter-Directed Embolectomy. AJP Rep 2024; 14:e140-e144. [PMID: 38736706 PMCID: PMC11087143 DOI: 10.1055/a-2299-4026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 03/27/2024] [Indexed: 05/14/2024] Open
Abstract
Introduction Pulmonary embolism (PE) is associated with approximately 10.5% of maternal deaths in the United States. Despite heightened awareness of its mortality potential, there islittle data available to guide its management in pregnancy. We present the case of a massive PE during gestation successfully treated with catheter-directed embolectomy. Case Presentation A 37-year-old G2P1001 presented with a syncopal episode preceded by dyspnea and chest pain. Upon presentation, she was hypotensive, tachycardiac, and hypoxic. Imaging showed an occlusive bilateral PE, right heart strain, and a possible intrauterine pregnancy. Beta-human chorionic gonadotropin was positive. She was taken emergently for catheter-directed embolectomy. Her condition immediately improved afterward. Postprocedure pelvic ultrasound confirmed a viable intrauterine pregnancy at 10 weeks gestation. She was discharged with therapeutic enoxaparin and gave birth to a healthy infant at 38 weeks gestation. Conclusion Despite being the gold standard for PE treatment in nonpregnant adults, systemic thrombolysis is relatively contraindicated in pregnancy due to concern for maternal or fetal hemorrhage. Surgical or catheter-based thrombectomies are rarely recommended. Limited alternative options force their consideration, particularly in a hemodynamically unstable patient. Catheter-directed embolectomy can possibly bypass such complications. Our case exemplifies the consideration of catheter-directed embolectomy as the initial treatment modality of a hemodynamically unstable gestational PE.
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Affiliation(s)
- Rachel D. Truong
- Department of Internal Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Sarah Cheyney
- Department of Pulmonary and Critical Care Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Mai Vo
- Department of Pulmonary and Critical Care Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Joel Garcia
- Department of Interventional Cardiology, Orlando Regional Medical Center, Orlando, Florida
| | - Neeraj N. Desai
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Winnie Palmer Hospital, Orlando, Florida
| | - Jacqueline Kropf
- Department of Hematology and Medical Oncology, Orlando Health Cancer Institute, Orlando, Florida
| | - Hatem Hassanein
- Department of Hematology and Medical Oncology, Orlando Health Cancer Institute, Orlando, Florida
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3
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Urriago-Osorio GA, Melo-Burbano LÁ, López-Van Den Berghe J, Muñoz-Córdoba AM, Daza-Arana JE, Contreras-Zúñiga E. Pulmonary Thromboembolism in Pregnancy: A Case Report and Literature Review. Open Access Emerg Med 2023; 15:217-225. [PMID: 37292453 PMCID: PMC10246571 DOI: 10.2147/oaem.s404941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 04/18/2023] [Indexed: 06/10/2023] Open
Abstract
Data on the optimal diagnostic management of pregnant women with suspected pulmonary embolism are limited. Despite a lack of compelling evidence in some practices, clinical practice guidelines focus on the management of these patients. We present the case of a 24-year-old patient at 36 weeks of pregnancy in whom pulmonary thromboembolism (PTE) was diagnosed in a timely manner also with hemodynamic instability and echocardiographic images with clear involvement of the right cavities. She received thrombolytic therapy with alteplase 100 mg intravenously over 2 hours, which resulted in excellent outcomes for both the pregnant woman and fetus. Understanding the acute approach and management of these patients will improve our clinical practice; therefore, we reviewed a case report of a pregnant patient with high-risk PTE and compared it with current evidence. In conclusion, PE is a common disease with a high mortality rate during pregnancy. Therefore, having made a timely diagnosis using the relevant diagnostic aids and performing thrombolysis with rtPA increase the probability of survival in our patient, leading to successful results for both her and the fetus.
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Affiliation(s)
- Gustavo Andrés Urriago-Osorio
- Department of Health, Internal Medicine Specialization Program, Universidad Santiago de Cali, Santiago de Cali, Colombia
- Emergency Department, Clínica de Occidente S.A, Santiago de Cali, Colombia
| | - Luis Álvaro Melo-Burbano
- Department of Health, Internal Medicine Specialization Program, Universidad Santiago de Cali, Santiago de Cali, Colombia
- Emergency Department, Clínica de Occidente S.A, Santiago de Cali, Colombia
| | | | | | - Jorge Enrique Daza-Arana
- Department of Health, Internal Medicine Specialization Program, Universidad Santiago de Cali, Santiago de Cali, Colombia
- Health and Movement Research Group, Universidad Santiago de Cali, Santiago de Cali, Colombia
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Webster LA, Bishay V. Venous Thromboembolism Management in Pregnant Patients. Tech Vasc Interv Radiol 2023; 26:100901. [PMID: 37865451 DOI: 10.1016/j.tvir.2023.100901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
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.
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Affiliation(s)
- Linzi A Webster
- Division of Vascular and Interventional Radiology, Department of Diagnostic, Molecular & Interventional Radiology, Mount Sinai Health System, New York, NY
| | - Vivian Bishay
- Division of Vascular and Interventional Radiology, Department of Diagnostic, Molecular & Interventional Radiology, Mount Sinai Health System, New York, NY.
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5
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Cueto-Robledo G, Cervantes-Naranjo FD, Gonzalez-Hermosillo LM, Roldan-Valadez E, Graniel-Palafox LE, Castro-Escalante KY, Orozco-Zuñiga B. Pulmonary embolism during pregnancy: an updated review with case series description. Curr Probl Cardiol 2023; 48:101683. [PMID: 36898596 DOI: 10.1016/j.cpcardiol.2023.101683] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/02/2023] [Indexed: 03/12/2023]
Abstract
Pulmonary embolism (PE) is a potentially life-threatening condition that can occur during pregnancy and pose a significant risk to the mother and the developing fetus. It is a major contributor to pregnancy-related morbidity and mortality in any trimester. It is estimated that the incidence of PE during pregnancy is approximately 1 in 1000 pregnancies. The mortality rate for pregnant women with PE is about 3%, significantly higher than that for non-pregnant women with PE. Overall, the topic of PE and pregnancy is essential for healthcare professionals to be aware of the risks, signs, and treatment options to improve outcomes and ensure the best possible care for both the mother and the developing fetus. To prevent the fatal condition, the physician is encouraged when there is a suspicion of the pathology. This report presents an updated comprehensive review of PE during pregnancy, discussing critical aspects of the clinical and imaging diagnosis, use of heparin, thrombolysis, and prevention. We believe this article will be helpful for cardiologists, obstetricians, and other health-related professionals.
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Affiliation(s)
- Guillermo Cueto-Robledo
- Cardiorespiratory Emergencies, Hospital General de México "Dr Eduardo Liceaga", 06720, Mexico City, Mexico; Pulmonary Circulation Clinic, Hospital General de México "Dr. Eduardo Liceaga", 06720, Mexico City, Mexico; Faculty of Medicine, National Autonomous University of Mexico, 04510, Mexico City, Mexico.
| | | | | | - Ernesto Roldan-Valadez
- Directorate of Research, Hospital General de Mexico "Dr. Eduardo Liceaga," 06720, Mexico City, Mexico; I.M. Sechenov First Moscow State Medical University (Sechenov University), Department of Radiology, 119992, Moscow, Russia.
| | | | | | - Benjamin Orozco-Zuñiga
- Ginecology Department, Hospital General de México ¨Dr. Eduardo Liceaga¨, Mexico City, Mexico.
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Poor H, Serrao G, Grapsa J, Chandrashekhar YS, Bianco A, Lookstein RA, Fuster V. High-Risk Pulmonary Embolism During Labor: JACC Patient Care Pathways. J Am Coll Cardiol 2023; 81:283-291. [PMID: 36265527 DOI: 10.1016/j.jacc.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/04/2022] [Accepted: 10/06/2022] [Indexed: 11/08/2022]
Abstract
While in labor, a 37-year-old woman developed acute dyspnea, hypoxemia, and tachycardia. Transthoracic echocardiography demonstrated severe right ventricular dilation and dysfunction, raising the suspicion of acute pulmonary embolism. The patient indeed had bilateral pulmonary embolism, necessitating percutaneous thrombectomy. Her course was complicated by another saddle pulmonary embolus, heparin-induced thrombocytopenia, and COVID-19 infection. This clinical case illustrates the importance of prompt diagnosis of acute pulmonary embolism in a peripartum female patient, the multidisciplinary approach of management, and how to approach clinical complications such as heparin-induced thrombocytopenia. Furthermore, long-term management in acute pulmonary embolism is presented.
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Affiliation(s)
- Hooman Poor
- Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Gregory Serrao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Julia Grapsa
- Department of Cardiovascular Sciences, Guys and St Thomas NHS Trust, Long, United Kingdom
| | | | - Angela Bianco
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Robert A Lookstein
- Department of Diagnostic, Molecular, and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Valentin Fuster
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Poor H, Serrao G, Grapsa J, Chandrashekhar Y, Bianco A, Lookstein RA, Fuster V. High-Risk Pulmonary Embolism During Labor: JACC Patient Care Pathways. JACC Case Rep 2022; 6:101650. [PMID: 36704055 PMCID: PMC9871077 DOI: 10.1016/j.jaccas.2022.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/04/2022] [Accepted: 10/06/2022] [Indexed: 11/08/2022]
Abstract
While in labor, a 37-year-old woman developed acute dyspnea, hypoxemia, and tachycardia. Transthoracic echocardiography demonstrated severe right ventricular dilation and dysfunction, raising the suspicion of acute pulmonary embolism. The patient indeed had bilateral pulmonary embolism, necessitating percutaneous thrombectomy. Her course was complicated by another saddle pulmonary embolus, heparin-induced thrombocytopenia, and COVID-19 infection. This clinical case illustrates the importance of prompt diagnosis of acute pulmonary embolism in a peripartum female patient, the multidisciplinary approach of management, and how to approach clinical complications such as heparin-induced thrombocytopenia. Furthermore, long-term management in acute pulmonary embolism is presented.
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Key Words
- CT, computed tomography
- CTA, computed tomography angiogram
- CTPA, computed tomography pulmonary angiography
- ECMO, extracorporeal membrane oxygenation
- HIT, heparin-induced thrombocytopenia
- LV, left ventricle
- PE, pulmonary embolism
- PVR, pulmonary vascular resistance
- RV, right ventricle
- SBP, systolic blood pressure
- TTE, transthoracic echocardiogram
- multimodality imaging
- pregnancy
- pulmonary embolism
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Affiliation(s)
- Hooman Poor
- Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA,Address for correspondence: Dr Hooman Poor, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, 10 East 102nd Street, New York, New York 10029, USA. @jgrapsa
| | - Gregory Serrao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Julia Grapsa
- Department of Cardiovascular Sciences, Guys and St Thomas NHS Trust, Long, United Kingdom
| | | | - Angela Bianco
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Robert A. Lookstein
- Department of Diagnostic, Molecular, and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Valentin Fuster
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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8
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Obstetric Disorders and Critical Illness. Clin Chest Med 2022; 43:471-488. [PMID: 36116815 DOI: 10.1016/j.ccm.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In this article, we discuss some of the more common obstetric-related conditions that can lead to critical illness and require management in an ICU. These include the hypertensive disorders of pregnancy, postpartum hemorrhage, hemolysis, elevated liver enzymes, and low platelet syndrome, acute fatty liver of pregnancy, amniotic fluid embolism, and peripartum cardiomyopathy. We also discuss pulmonary embolism and Covid-19. Despite not being specific to obstetric patients, pulmonary embolism is a common, life-threatening diagnosis in pregnancy with particular risks and management aspects. Covid-19 does not seem to occur with higher frequency in pregnant women, but it leads to higher rates of ICU admissions and mechanical ventilation in pregnant women than in their nonpregnant peers. Its prevalence during our current global pandemic makes it important to discuss in this article. We provide a basis for critical care physicians to be engaged in informed conversations and management in a multidisciplinary manner with other relevant providers in the care of critically ill pregnant and postpartum women.
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9
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O’Kelly AC, Ludmir J, Wood MJ. Acute Coronary Syndrome in Pregnancy and the Post-Partum Period. J Cardiovasc Dev Dis 2022; 9:jcdd9070198. [PMID: 35877560 PMCID: PMC9319853 DOI: 10.3390/jcdd9070198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 11/16/2022] Open
Abstract
Cardiovascular disease is the leading cause of maternal mortality in the United States. Acute coronary syndrome (ACS) is more common in pregnant women than in non-pregnant controls and contributes to the burden of maternal mortality. This review highlights numerous etiologies of chest discomfort during pregnancy, as well as risk factors and causes of ACS during pregnancy. It focuses on the evaluation and management of ACS during pregnancy and the post-partum period, including considerations when deciding between invasive and non-invasive ischemic evaluations. It also focuses specifically on the management of post-myocardial infarction complications, including shock, and outlines the role of mechanical circulatory support, including veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Finally, it offers additional recommendations for navigating delivery in women who experienced pregnancy-associated myocardial infarction and considerations for the post-partum patient who develops ACS.
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Vyas N, Poonja N, Shetty B, Rai S. Pulmonary thromboembolism and its complications in a patient in labour. BMJ Case Rep 2022; 15:e248469. [PMID: 35232745 PMCID: PMC8889244 DOI: 10.1136/bcr-2021-248469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 11/04/2022] Open
Abstract
Venous thromboembolic event in pregnancy is a rare but dreaded complication. When it occurs in labour, it presents with sudden severe fetal distress and maternal haemodynamic compromise. We present to you a case where in patient was taken up for emergency caesarean section for severe fetal distress. Intraoperative ECG showed right heart strain. Hence, an immediate bedside echocardiography was done in medical intensive care unit and it picked up a swirling thrombus in right atrium which immediately got dislodged to pulmonary vessels. Postcaesarean, we faced challenge of controlling active bleeding from atonic uterus with non-surgical techniques (Bakri balloon tamponade and uterine artery embolisation) before considering anticoagulation therapy for pulmonary embolism. The patient recovered well after anticoagulation treatment.
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Affiliation(s)
- Neetha Vyas
- OBG, KS Hegde Medical Academy, Mangalore, Karnataka, India
| | - Neetha Poonja
- OBG, KS Hegde Medical Academy, Mangalore, Karnataka, India
| | - Balika Shetty
- OBG, KS Hegde Medical Academy, Mangalore, Karnataka, India
| | - Supriya Rai
- OBG, KS Hegde Medical Academy, Mangalore, Karnataka, India
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Inter-Specialty Controversies on the Treatment of Cardiovascular Diseases during Pregnancy: A Questionnaire Study. Medicina (B Aires) 2022; 58:medicina58010138. [PMID: 35056446 PMCID: PMC8780357 DOI: 10.3390/medicina58010138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/09/2022] [Accepted: 01/12/2022] [Indexed: 11/17/2022] Open
Abstract
Background and Objectives: Management of cardiovascular disease (CVD) during pregnancy is challenging and usually requires eminence-based decisions due to limited strong-evidence data in this field. The purpose of our study was to compare the attitudes of anaesthesiologists, cardiologists, and gynaecologists towards the diagnosis and treatment of potentially life-threatening CVDs during pregnancy. Materials and Methods: A cross-sectional, questionnaire-based study was performed among 111 doctors (55 anaesthesiologists, 36 cardiologists, 20 gynaecologists). Personal opinions on the recommendations (n = 19) regarding rare, potentially life-threatening CVDs during pregnancy were recorded using a five-item Likert scale. Results: Opinions regarding eight statements (42%) varied substantially between specialties (p < 0.05). The most distinctive differences between physicians concerned the following recommendations: “thrombolysis should only be used in pulmonary embolism with cardiogenic shock” (agree: 52.7% of anaesthesiologists, 80.4% of cardiologists, 25.0% of gynaecologists; p < 0.001); “women with the antiphospholipid syndrome should restart treatment with vitamin K antagonists from the second trimester of pregnancy” (agree: 12.7% of anaesthesiologists, 69.4% of cardiologists, 20.0% of gynaecologists; p < 0.001); “women with symptomatic pulmonary hypertension should have a Swan–Ganz catheter inserted for labour” (agree: 20.0% of anaesthesiologists, 11.1% of cardiologists, 55.0% of gynaecologists; p = 0.001). Conclusions: Physicians’ opinions regarding diagnostics and treatment of CVDs in pregnancy remain controversial. A multidisciplinary approach is recommended to ensure the safety and effectiveness of management in these unique medical conditions.
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Brenner B, Grandone E, Makatsariya A, Khizroeva J, Bitsadze V, Tretyakova M. Approach to the Evaluation and Treatment of Venous Thromboembolism in Pregnancy. Semin Reprod Med 2021; 39:186-193. [PMID: 34560808 DOI: 10.1055/s-0041-1736188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Thrombosis in pregnancy is a major cause of maternal and fetal morbidity and mortality. Risk stratification of venous thromboembolism (VTE) during pregnancy is complex. The hypercoagulability observed in pregnant women can reduce bleeding during childbirth, but may cause thrombosis especially in the presence of additional prothrombotic risk factors such as antiphospholipid antibodies or genetic thrombophilic defects. The availability of large datasets allows for the identification of additional independent risk factors, including assisted reproductive technologies (ARTs), endometriosis, and recurrent pregnancy loss. Data on the risk of VTE linked to COVID-19 in pregnant women are very limited, but suggest that infected pregnant women have an increased risk of VTE. Current guidelines on the prevention and treatment of VTE in pregnancy are based on available, albeit limited, data and mainly present expert opinion. Low-molecular-weight heparins (LMWHs) are the mainstay of anticoagulation to be employed during pregnancy. Administration of LMWH for VTE treatment in pregnancy should be based on the personalized approach, taking into account a weight-based adjusted scheme. During gestation, due to physiological changes, in women at high risk of VTE, monitoring of anti-Xa activity is performed to ensure adequate LMWH dosing. As for the treatment duration for pregnant women with acute VTE, guidelines suggest that anticoagulation should be continued for at least 6 weeks postpartum for a minimum total duration of therapy of 3 months.
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Affiliation(s)
- Benjamin Brenner
- Department of Hematology, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.,Department of Obstetrics and Gynaecology, The First I.M. Sechenov Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Elvira Grandone
- Department of Obstetrics and Gynaecology, The First I.M. Sechenov Moscow State Medical University (Sechenov University), Moscow, Russia.,Thrombosis and Haemostasis Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza," San Giovanni Rotondo, Italy
| | - Alexander Makatsariya
- Department of Obstetrics and Gynaecology, The First I.M. Sechenov Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Jamilya Khizroeva
- Department of Obstetrics and Gynaecology, The First I.M. Sechenov Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Victoria Bitsadze
- Department of Obstetrics and Gynaecology, The First I.M. Sechenov Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Maria Tretyakova
- Department of Obstetrics and Gynaecology, The First I.M. Sechenov Moscow State Medical University (Sechenov University), Moscow, Russia
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Systemic Thrombolysis for Treatment of Postpartum Saddle Embolism Complicated by Postpartum Hemorrhage: A Case Report and Brief Literature Review. Case Rep Obstet Gynecol 2021; 2021:5553296. [PMID: 34306779 PMCID: PMC8263235 DOI: 10.1155/2021/5553296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 05/01/2021] [Accepted: 06/14/2021] [Indexed: 11/26/2022] Open
Abstract
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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14
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Clinical outcomes of very elderly patients treated with ultrasound-assisted catheter-directed thrombolysis for pulmonary embolism: a systematic review. J Thromb Thrombolysis 2021; 52:260-271. [PMID: 33665765 DOI: 10.1007/s11239-021-02409-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2021] [Indexed: 10/22/2022]
Abstract
Pulmonary embolism (PE) is a significant cause of death in the very elderly (≥ 75 years) population. Ultrasound-assisted catheter-directed thrombolysis (USCDT) emerges to improve thrombolysis safety and efficacy. However, outcomes in very elderly patients are unknown, as randomized controlled trials exclude this population. Recently, we demonstrated acute kidney injury (AKI) and ischemic hepatitis in an octogenarian intermediate-risk PE patient treated with USCDT. Considering the lack of evidence, we undertook a systematic review to evaluate the clinical outcomes in very elderly PE patients treated with USCDT. We searched for very elderly PE patients treated with USCDT from 2008 to 2019. Additionally, we conducted another systematic review without age restriction to update previous evidence and compare both populations. We also did an exploratory analysis to determine if thrombolysis was followed based on current guidelines or impending clinical deterioration factors. We identified 18 very elderly patients (age 79.2, 75-86), mostly female and with intermediate-risk PE. We found an intracranial hemorrhage (ICH), and a right pulmonary artery rupture. Additionally, two significant bleedings complicated with transient AKI, and one case of AKI and ischemic hepatic injury. The patients who survived all had clinical and echocardiographic in-hospital improvement. Despite low rt-PA doses, ICH and major bleeding remain as feared complications. Thrombolysis decision was driven by impending clinical deterioration factors instead of international guideline recommendations. Our data do not suggest prohibitive risk associated with USCDT in very elderly intermediate and high-risk PE patients. Despite long-term infusions and right ventricular dysfunction, AKI and ischemic hepatic injury were infrequent.
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Jerjes-Sánchez C, Rodriguez D, Farjat AE, Kayani G, MacCallum P, Lopes RD, Turpie AGG, Weitz JI, Haas S, Ageno W, Goto S, Goldhaber SZ, Angchaisuksiri P, Nielsen JD, Schellong S, Bounameaux H, Mantovani LG, Prandoni P, Kakkar AK. Pregnancy-Associated Venous Thromboembolism: Insights from GARFIELD-VTE. TH OPEN 2021; 5:e24-e34. [PMID: 33532693 PMCID: PMC7840428 DOI: 10.1055/s-0040-1722611] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 11/30/2020] [Indexed: 12/31/2022] Open
Abstract
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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Affiliation(s)
- Carlos Jerjes-Sánchez
- Tecnologico de Monterrey. Escuela de Medicina y Ciencias de la Salud, Instituto de Cardiologia y Medicina Vascular, TecSalud, Monterrey, Mexico
| | - David Rodriguez
- Tecnologico de Monterrey. Escuela de Medicina y Ciencias de la Salud, Instituto de Cardiologia y Medicina Vascular, TecSalud, Monterrey, Mexico
| | | | - Gloria Kayani
- Thrombosis Research Institute, London, United Kingdom
| | - Peter MacCallum
- Thrombosis Research Institute, London, United Kingdom.,Queen Mary University of London, London, United Kingdom
| | - Renato D Lopes
- Division of Cardiology, Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina, United States
| | | | - Jeffrey I Weitz
- McMaster University, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Tokai, Japan
| | | | | | | | | | | | - Lorenzo G Mantovani
- IRCCS Multimedica Milan, Milan, Italy.,University of Milano, Bicocca, Milan, Italy
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Abstract
Pregnancy and postpartum represent periods at very high risk of venous thromboembolism disease which appears to extend well beyond the classic 6-8 weeks after childbirth. Pulmonary embolism (PE) is still one of the three leading causes of direct maternal death (MM) in most developed countries. Between 2013 and 2015, 23 maternal deaths were caused by a venous thromboembolic complication (VTE) (20 pulmonary embolism and 3 cerebral thrombophlebitis), representing 8.8 % of maternal deaths and a Maternal Mortality Ratio of 1.0 per 100,000 live births (95 % CI 0.6-1, 4) which is stable over the last 10 years. Regarding the timing of death, 1 death occurred after abortion, 35 % (8/23) during an ongoing pregnancy (including four before 22 WG), and 61 % (14/23) after childbirth. Among the 23 deaths from VTE, 17 % (5/23) occurred outside a healthcare center (home, street). The mean age was 32.3 and 7 women (30 %) were≥35 years old. Six patients were obese (27 %). The preventability rate is 34.8 % (compared to 50 % in 2007-2009 and 2010-2012), The preventability factors involve the inadequacy of care in 34.8 % of cases (8/23), organizational factors in one case (1/23) and a lack of interaction of the patient with the health care system in two cases (2/23). Care was considered non-optimal in 59 % of these deaths. This proportion is higher than the preventability rate because suboptimal care sometimes did not influence the final outcome.
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