What to Do When They’re Eating for Two? A Case of Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism in Pregnancy

Main Article Content

James Michael Radford

Abstract

ABSTRACT
A 33-year-old G7P0 female at 8 weeks gestation presented to the emergency department (ED) following a syncopal episode. She complained of chest pain and dyspnea, and had hemodynamic instability, which responded to intravenous fluids. Continued fluid resuscitation, supplemental oxygen, as well as therapeutic dose low molecular weight heparin (LMWH) were administered in the ED. Computed tomography (CT) pulmonary angiogram confirmed saddle pulmonary embolism (PE). After 12 h of continued chest pain and high oxygen requirements, a decision was made to use catheter-directed thrombolysis (CDT) involving alteplase with manual thrombus maceration in bilateral pulmonary arteries. There were no immediate hemorrhagic complications and follow-up fetal ultrasound demonstrated a normal viable intrauterine pregnancy. She clinically improved and was discharged on LMWH. Cesarean section was scheduled, and the patient delivered a healthy term infant at 37 weeks gestation without complications. Our case demonstrates that CDT may be a safe and effective treatment for submassive PE in pregnancy.



RÉSUMÉ
Une femme âgée de 33 ans et enceinte de huit semaines (G7P0) se présente aux urgences à la suite d’un épisode syncopal. Elle se plaint de douleurs thoraciques et de dyspnée et présente une instabilité hémodynamique qui répond aux solutés intraveineux. Une réanimation liquidienne continue, une oxygénothérapie ainsi qu’une dose thérapeutique d’héparine de faible poids moléculaire sont administrées aux urgences. L’angiographie pulmonaire par tomodensitométrie confirme une embolie pulmonaire en selle. Après 12 heures de douleurs thoraciques continues et de besoins élevés en oxygène, on décide d’utiliser la thrombolyse dirigée par cathéter (TDC) à l’aide de l’altéplase avec macération manuelle du thrombus dans les artères pulmonaires bilatérales. Il n’y a pas eu de complications hémorragiques immédiates et le suivi échographique du fœtus a démontré une grossesse intra utérine normale et viable. Son état clinique s’est amélioré et elle a obtenu son congé sous héparine de faible poids moléculaire. Une césarienne a été planifiée et la patiente a accouché d’un enfant à terme et en bonne santé à 37 semaines de grossesse, sans complications. Notre cas démontre que la TDC peut être un traitement sûr et efficace de l’embolie pulmonaire submassive en cours de grossesse.

Abstract 102 | pdf Downloads 25 HTML Downloads 33

References

1. Hirshberg A, Srinivas SK. Epidemiology of maternal morbidity and mortality. Semin Perinatol. 2017;41(6):332–7. http://dx.doi.org/10.1053/j.semperi.2017.07.007
2. Chan WS, Ray JG, Murray S, et al. Suspected pulmonary embolism in pregnancy. Arch Intern Med. 2002;162(10):1170. http://dx.doi.org/10.1001/archinte.162.10.1170
3. Bates SM, Rajasekhar A, Middeldorp S, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: Venous thromboembolism in the context of pregnancy. Blood Adv. 2018;2(22):3317–59. http://dx.doi.org/10.1182/bloodadvances.2018024802
4. Jaff MR, McMurtry MS, Archer SL, et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: A scientific statement from the american heart association. Circulation. 2011;123(16):1788–830. http://dx.doi.org/10.1161/CIR.0b013e318214914f
5. Hao Q, Dong BR, Yue J, et al. Thrombolytic therapy for pulmonary embolism. Cochrane Database Syst Rev. 2015;2015(9). http://dx.doi.org/10.1002/14651858.CD004437.pub4
6. Konstantinides SV, Vicaut E, Danays T, et al. Impact of thrombolytic therapy on the long-term outcome of intermediate-risk pulmonary embolism. J Am Coll Cardiol. 2017;69(12):1536–44. http://dx.doi.org/10.1016/j.jacc.2016.12.039
7. Kucher N, Boekstegers P, Müller OJ, et al. Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism. Circulation. 2014;129(4):479–86. http://dx.doi.org/10.1161/CIRCULATIONAHA.113.005544
8. Kuo WT, Banerjee A, Kim PS, et al. Pulmonary embolism response to fragmentation, embolectomy, and catheter thrombolysis (PERFECT). Chest. 2015;148(3):667–73. http://dx.doi.org/10.1378/chest.15-0119
9. Piazza G, Hohlfelder B, Jaff MR, et al. A prospective, single-arm, multicenter trial of ultrasound-facilitated, catheter-directed, low-dose fibrinolysis for acute massive and submassive pulmonary embolism: The SEATTLE II study. JACC Cardiovasc Interv. 2015;8(10):1382–92. http://dx.doi.org/10.1016/j.jcin.2015.04.020
10. Krishnamurthy P, Martin CB, Kay HH, et al. Catheter-directed thrombolysis for thromboembolic disease during pregnancy: A viable option. J Matern Neonatal Med. 1999;8(1):24–7. http://dx.doi.org/10.3109/14767059909063149
11. Pick J, Berlin D, Horowitz J, et al. Massive pulmonary embolism in pregnancy treated with catheter-directed tissue plasminogen activator. A A Case Rep. 2015;4(7):91–4. http://dx.doi.org/10.1213/XAA.0000000000000128
12. Garbarino A, Miller N, Tatem G. Successful catheter-directed thrombolysis for pulmonary embolism during pregnancy. Am J Respirol Crit Care Med. 2017;195:A6212. http://dx.doi.org/10.1164/ajrccm-conference.2017.195.1_MeetingAbstracts.A6212
13. O’Keeffe SA, McGrath A, Ryan JM, et al. Management of a massive pulmonary embolism in a pregnant patient with mechanical fragmentation followed by delayed catheter-directed thrombolysis in the early postpartum period. J Matern Neonatal Med. 2008;21(8):591–4. http://dx.doi.org/10.1080/14767050802165604
14. Weinberg L, Kay C, Liskaser F, et al. Successful treatment of peripartum massive pulmonary embolism with extracorporeal membrane oxygenation and catheter-directed pulmonary thrombolytic therapy. Anaesth Intensive Care. 2011;39(3):486–91. http://dx.doi.org/10.1177/0310057x1103900323
15. Sofocleous CT, Hinrichs C, Bahramipour P, et al. Percutaneous management of life-threatening pulmonary embolism complicating early pregnancy [3]. J Vasc Interv Radiol. 2001;12(11):1355–6. http://dx.doi.org/10.1016/S1051-0443(07)61566-8
16. Bechtel JJ, Mountford MC, Ellinwood WE. Massive pulmonary embolism in pregnancy treated with catheter fragmentation and local thrombolysis. Obstet Gynecol. 2005;106(5):1158–60. http://dx.doi.org/10.1097/01.AOG.0000164058.63244.9c
17. Ho VT, Dua A, Lavingia K, et al. Thrombolysis for venous thromboembolism during pregnancy: A literature review. Vasc Endovascular Surg. 2018;52(7):527–34. http://dx.doi.org/10.1177/1538574418777822
18. Kuo WT. Endovascular therapy for acute pulmonary embolism. J Vasc Interv Radiol. 2012;23(2):167–179.e4. http://dx.doi.org/10.1016/j.jvir.2011.10.012
19. Sharifi M, Bay C, Skrocki L, et al. Moderate pulmonary embolism treated with thrombolysis (from the “mOPETT” trial). Am J Cardiol. 2013;111(2):273–7. http://dx.doi.org/10.1016/j.amjcard.2012.09.027
20. McCollough CH, Schueler BA, Atwell TD, et al. Radiation exposure and pregnancy: When should we be concerned? RadioGraphics. 2007;27:909–18. http://dx.doi.org/10.1016/s0098-1672(08)79159-8