Thrombolysis for massive pulmonary embolism in pregnancy: a case report

Massive pulmonary embolism (MPE) is the leading cause of maternal mortality in the developed world. Mortality from PE in pregnancy might be related to challenges in targeting the right population for prevention. Such targeting could help ensure that the correct diagnosis is suspected and adequately investigated, and allow the initiation of the timely and best possible treatment of this disease. Thrombolytic drugs can be considered for the treatment of patients who are hemodynamically unstable, or of patients with refractory hypoxemia [1] or right ventricular dysfunction on echocardiogram [2,3]. However, the high risk of major bleeding (in 4%-14% of treated patients with thrombolysis) limits their use [4]. Although pregnancy-specific complications do arise, including spontaneous pregnancy loss, placental abruption, and preterm labor, it is not clear whether they are caused by the underlying disease, its treatment, or neither. We present here the case of a pregnant patient with massive PE (MPE) who was hospitalized 4 h after onset of sudden acute dyspnea and chest pain, and successfully thrombolysed.A 26-year-old pregnant (at 24 weeks) woman was referred to the emergency department (ED) of our hospital ("G.F. Ingrassia" Palermo, Italy) 4 h after onset of sudden acute dyspnea and chest pain. No risk factors or drug consumption was present in the patient's clinical history. On admission to the ED, the patient was dyspneic, cyanotic, hemodynamically unstable, hypotensive (70/50 mmHg), and tachycardic (125 beats/min), with low oxygen saturation (80%) in oxygen with a Venturi mask (6 L/min), with a respiratory rate of 28-30 breaths/min, and with primary hypoxemia and metabolic acidosis (pH 7.29; PO2 51 mmHg, PCO2 30 mmHg, HCO3 20 mmol/L).Immediate electrocardiogram showed sinus tachycardia with a typical S1-Q3-T3 pattern (Figure 1). After first aid consisting of intravenous line placement, oxygen treatment, and fluid infusion, the patient was transferred to the cardiology