Massive pulmonary embolism in pregnancy

ABSTRACT

Venous thromboembolic disease [VTE], including deep venous thrombosis [DVT] and pulmonary embolism [PE] is not uncommon during pregnancy. High degree of suspicion should be maintained, as many clinical features of VTE are common during pregnancy such as lower extremity swelling and increased respiratory rate. Threshold to investigate VTE should be low as it is associated with significant morbidity and mortality. Diagnostic tests [venous Doppler, echocardiography, spiral CT, V/Q scan, pulmonary arteriography] should be carefully chosen as dictated by the clinical situation and availability of tests and expertise. DVT or hemodynamically insignificant pulmonary embolism may be managed with systemic anticoagulation. Unfractionated heparin requires continuous intravenous infusion and activated partial thromboplastin time should be monitored. Low molecular weight heparin is safe, can be administered subcutaneously and does not require monitoring unless bleeding is noticed. In the absence of contraindications systemic or local catheter-directed thrombolysis should be attempted for hemodynamically significant pulmonary embolism. Surgical thrombectomy should be considered if thrombolytic therapy is contraindicated. After thrombolysis or thrombectomy, long-term anticoagulation is warranted to prevent recurrence. Warfarin is contraindicated in early pregnancy and risk of bleeding is potentially higher late in pregnancy