Pulmonary Embolism and Pregnancy

Pulmonary embolism (PE) is a leading cause of maternal mortality during pregnancy and following delivery. Pregnancy is associated with a variety of anatomical, hormonal and biochemical alterations that predispose towards venous thrombosis and PE. A high index of suspicion is critical in making the diagnosis, which can be confirmed by objective testing with lower extremity Doppler ultrasound, lung scintigraphy or CT angiography. Treatment in the acute setting typically includes intravenous UFH, subcutaneous LMWH or subcutaneous UFH, with transition to subcutaneous regimens for the duration of the pregnancy. Interventions in pregnant women with massive (hemodynamically unstable) PE include: positioning in a left lateral decubitus position, volume resuscitation, and supplemental oxygen. IVC filters may be helpful, as they can be for non-pregnant patients. Although experience is limited, systemic or catheter directed thrombolytic therapy have been reported to be successful in treatment of massive PE in pregnant patients with relatively low maternal and fetal mortality. Invasive therapies such as surgical embolectomy for severely ill pregnancy women with massive PE might be instituted depending on the patient acuity and the available resources and expertise.