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Rodriguez D, Jerjes-Sanchez C, Fonseca S, Garcia-Toto R, Martinez-Alvarado J, Panneflek J, Ortiz-Ledesma C, Nevarez F. Thrombolysis in massive and submassive pulmonary embolism during pregnancy and the puerperium: a systematic review. J Thromb Thrombolysis 2021; 50:929-941. [PMID: 32347509 DOI: 10.1007/s11239-020-02122-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Thrombolysis in high-risk pulmonary embolism (PE) patients is recommended worldwide; however, the evidence for thrombolysis during pregnancy and the immediate puerperium remains unclear. We conducted a systematic review from 1950 to 2019 through PubMed, Ovid/Willey, and Cochrane Library to assess the safety and effectiveness of thrombolysis during pregnancy and the immediate puerperium. Additionally, we characterized the clinical presentation, risk stratification, and diagnostic approach. We have communicated our results according to the PRISMA statement. We collected 141 records and, after critical assessment, included 47 case reports of 54 patients, including 43 and 11 patients during pregnancy and puerperium, respectively. During pregnancy, alteplase was the most frequent systemic thrombolytic agent used (67%), but only nine patients received the approved FDA regimen. With catheter-directed thrombolysis, low-dose thrombolytics and fragmentation were the most common regimens. Major bleeding occurred in 18% of cases, but there was no intracranial bleeding. One maternal death occurred secondary to refractory cardiogenic shock. Fetal mortality was 20%. During the immediate puerperium, nine patients received "off-label" first-, second-, and third-generation thrombolytic regimens, and four cases underwent catheter-directed thrombolysis. We observed nine major bleeding events, seven of which were from the uterine location and none of which were intracranial. In conclusion, overall, these data do not suggest prohibitive risk associated with thrombolysis for PE in pregnancy. Management of massive and high-risk submassive PE in pregnancy should be individualized to each patient. In the data presented, no fatal bleeding or intracranial bleeding was observed. Finally, future efforts should systematically collect and report data on high-risk PE in pregnancy and peripartum patients to improve the evidence-base clinical practice.
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Affiliation(s)
- David Rodriguez
- Escuela de Medicina y Ciencias de La Salud, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico
- Centro de Investigacion Biomedica del Hospital Zambrano Hellion, TecSalud, San Pedro Garza García, Nuevo Leon, Mexico
- Instituto de Cardiología y Medicina Vascular, TecSalud, San Pedro Garza García, Nuevo Leon, Mexico
| | - Carlos Jerjes-Sanchez
- Escuela de Medicina y Ciencias de La Salud, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico.
- Centro de Investigacion Biomedica del Hospital Zambrano Hellion, TecSalud, San Pedro Garza García, Nuevo Leon, Mexico.
- Instituto de Cardiología y Medicina Vascular, TecSalud, San Pedro Garza García, Nuevo Leon, Mexico.
- Hospital Zambrano Hellion, Batallón de San Patricio 112, Real San Agustin, San Pedro Garza Garcia, Nuevo Leon, 66278, Mexico.
| | - Sugely Fonseca
- Internal Medicine, Hospital San José, TecSalud, Nuevo Leon, Monterrey, Mexico
| | | | | | | | - Claudia Ortiz-Ledesma
- Escuela de Medicina y Ciencias de La Salud, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico
| | - Francisco Nevarez
- Escuela de Medicina y Ciencias de La Salud, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico
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Lemoine S, Jost D, Barre-Drouard C, Tourtier JP. Re: Tawfik M.M., et al. "Circulatory collapse in a parturient undergoing cesarean delivery: a diagnostic dilemma.". Int J Obstet Anesth 2017; 33:97-98. [PMID: 28801159 DOI: 10.1016/j.ijoa.2017.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 06/22/2017] [Accepted: 06/25/2017] [Indexed: 12/29/2022]
Affiliation(s)
- S Lemoine
- Paris Fire Brigade Medical Emergency Department, Paris, France.
| | - D Jost
- Paris Fire Brigade Medical Emergency Department, Paris, France; Sudden Death Expertise Center (SDEC), Paris, France
| | - C Barre-Drouard
- Department of Anesthesiology, Jeanne de Flandre University Hospital, Lille, France
| | - J P Tourtier
- Paris Fire Brigade Medical Emergency Department, Paris, France
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Akazawa M, Nishida M. Thrombolysis with intravenous recombinant tissue plasminogen activator during early postpartum period: a review of the literature. Acta Obstet Gynecol Scand 2017; 96:529-535. [PMID: 28222238 DOI: 10.1111/aogs.13116] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 02/14/2017] [Indexed: 12/14/2022]
Abstract
Thromboembolic events are one of the leading causes of maternal death during the postpartum period. Postpartum thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) is controversial because the treatment may lead to massive bleeding. Data centralization may be beneficial for analyzing the safety and effectiveness of systemic thrombolysis during the early postpartum period. We performed a computerized MEDLINE and EMBASE search. We collected data for 13 cases of systemic thrombolytic therapy during the early postpartum period, when limiting the early postpartum period to 48 hours after delivery. Blood transfusion was necessary in all cases except for one (12/13; 92%). In seven cases (7/13; 54%), a large amount of blood was required for transfusion. Subsequent laparotomy to control bleeding was required in five cases (5/13; 38%), including three cases of hysterectomy and two cases of hematoma removal, all of which involved cesarean delivery. In cases of transvaginal delivery, there was no report of laparotomy. The occurrence of severe bleeding was high in relation to cesarean section, compared with vaginal deliveries. Using rt-PA in relation to cesarean section might be worth avoiding. However, the paucity of data in the literature makes it difficult to assess the ultimate outcomes and safety of this treatment.
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Affiliation(s)
- Munetoshi Akazawa
- Department of Obstetrics and Gynecology, Fukuoka Red Cross Hospital, Fukuoka, Japan
| | - Makoto Nishida
- Department of Obstetrics and Gynecology, Fukuoka Red Cross Hospital, Fukuoka, Japan
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Doumiri M, Motia Y, Oudghiri N, Tazi AS. [Systemic thrombolysis with tenecteplase for massive pulmonary embolism after a recent cesarean]. ACTA ACUST UNITED AC 2014; 33:603-5. [PMID: 25450735 DOI: 10.1016/j.annfar.2014.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Accepted: 08/26/2014] [Indexed: 10/24/2022]
Affiliation(s)
- M Doumiri
- Service d'anesthésie-réanimation, hôpital maternité Souissi, centre hospitalier universitaire Ibnsina, Rabat, Maroc.
| | - Y Motia
- Service d'anesthésie-réanimation, hôpital maternité Souissi, centre hospitalier universitaire Ibnsina, Rabat, Maroc
| | - N Oudghiri
- Service d'anesthésie-réanimation, hôpital maternité Souissi, centre hospitalier universitaire Ibnsina, Rabat, Maroc
| | - A S Tazi
- Service d'anesthésie-réanimation, hôpital maternité Souissi, centre hospitalier universitaire Ibnsina, Rabat, Maroc
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Shaulov T, David M, Pellerin M, Morin F. Massive Hemorrhage Following Thrombolysis for Postpartum Pulmonary Embolism With Cardiac Arrest. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2014; 36:498-501. [DOI: 10.1016/s1701-2163(15)30563-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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