Mahfooz Alam Farooqui, Mehar Ali Ayyaril.
Massive pulmonary embolism in pregnancy.
Pak J Med Sci Jan ;17(4):241-4.

Summary: 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.

Case Report: A 28 years old para 4, gravida 3 presented with 8th week of pregnancy and a history of palpitations, central chest discomfort and shortness of breath of one day duration. On examination she was obese with atrial fibrillation and a heart rate of 130 per minute, which spontaneously reverted to sinus tachycardia. She was mildly tachypnic with oxygen saturation of 94% on room air. Her Jugular Venous Pressure (JVP) was raised. Rest of the examination was unremarkable. Pulmonary embolism was suspected, as there was no obvious reason of her symptoms, raised JVP and tachypnea. Perfusion lungs scan showed multiple defects throughout the left lung and lower segment of right lung, interpreted as high probability of pulmonary embolism. Two-dimensional echocardiography showed dilated right ventricle with moderate tricuspid regurgitation and a pressure gradient of 35 mmHg across the valve. Patient was initially treated with full intravenous heparinization. She deteriorated hemodynamically and developed cold, clammy skin with impending shock. She was treated with intravenous recombinant tissue plasminogen activator (rTPA) 100 mg over 90 minutes. Large volume of intravenous fluids was also administered. The risk of abortion and severe placental hemorrhage was anticipated. Immediately after the infusion of rTPA she improved dramatically. Her blood pressure improved to 110/70 mmHg. Repeat 2-D echocardiography showed normal sized right ventricle with no tricuspid regurgitation. No untoward effects were noted and she made a good recovery. She remained well with no evidence of any pulmonary hypertension or recurrence of embolism. Her Ultrasound Doppler examination of leg veins did not show any DVT and serial echocardiography remained normal. Her protein C, Protein S, Antithrombin III and activated protein C resistance done before starting anticoagulants were normal. Other investigations including erythrocyte sedimentation rate, C-reactive protein, complements, antinuclear antibodies, cANCA and pANCA were within normal limits. Low molecular weight heparin was started and continued through out the pregnancy. At term she delivered a healthy baby. After delivery she was anticoagulated with warfarin for three months.

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