Successful catheter-directed thrombolysis for pulmonary embolism during pregnancy.
Garbarino A, Miller N, and Tatem G. Successful catheter-directed thrombolysis for pulmonary embolism during pregnancy. Am J Respir Crit Care Med 2017; 195.
Am J Respir Crit Care Med
Catheter-directed thrombolysis (EKOS) is considered to be high risk during pregnancy and postpartum. Little is known regarding its safety during pregnancy and few cases are reported. We present a patient who presented eleven weeks pregnant with a massive pulmonary embolus (PE) who underwent EKOS. A 29-year-old female 11 weeks pregnant (gravida 4, para 2) with past medical history significant for prior spontaneous abortion presented with acute shortness of breath. She endorsed left calf pain one day prior. Moments after arrival to the emergency department, she became pulseless and resuscitative efforts were initiated. She achieved return of spontaneous circulation after two minutes of advanced cardiac life support. CT angiography of the chest showed multiple segmental and subsegmental pulmonary emboli in all lung lobes with a large clot seen in the right main pulmonary artery (figure 1). She was given aspirin and started on heparin. She was not given thrombolytics in the ED due to her pregnancy and was transferred to the medical intensive care unit (MICU). Upon arrival to the MICU, cardiology was immediately contacted regarding candidacy for EKOS. Echocardiogram showed an ejection fraction of 35% and a hypokinetic left ventricle with signs of right heart strain. Troponins peaked at 35 ng/mL. She underwent EKOS procedure via right internal jugular under fluoroscopic guidance on day one of admission. Two milligrams of tissue plasminogen activator (t-PA) were injected into each PA and then a continuous t-PA infusion of 1.2mg/hr for 17 hours was administered. Heparin infusion at a rate of 500 units/hr was continued during this time. EKOS catheters were removed one day later without incident and enoxaparin was started for long-term anticoagulation. Transvaginal ultrasound following removal of EKOS catheters showed a viable intrauterine pregnancy. Obstetrics was consulted and recommended routine prenatal workup. Repeat echocardiogram three days post-EKOS showed EF 48% and persistent right ventricular dysfunction. She was discharged home one week after presentation with regular obstetric follow up. The fetus is currently at 33 weeks gestation with plans for C-section delivery at week 37. At this time, there are no studies available evaluating the safety of EKOS or systemic thrombolysis for PE during pregnancy. However, our patient suffered cardiovascular collapse secondary to the PE and had excellent response to EKOS therapy. Despite high complication rates of thrombolytic therapy, current data do not justify withholding EKOS from pregnant women in the case of life-threatening PE. [Image Presented].