Pregnancy and pulmonary embolism; a fatal challenge: literature review

Document Type : Review Article

Authors

1 Assistant Professor, Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

2 Gynecologist, Mashhad University of Medical Sciences, Mashhad, Iran

Abstract

Introduction: Pulmonary embolism, as a relatively common non-obstetrics complication, is an important cause of maternal mortality during pregnancy. Due to some physiological and hormonal changes, the risk of pulmonary embolism increases during pregnancy and postpartum. This review article was performed with aim to explore the last articles related to diagnostic methods and treatment of this disease.  
Methods: In this review article, databases of Google scholar, PubMed, Embase, Medline, Iranmedex and IranDoc were systematically searched using the keywords of pulmonary embolism, thromboembolism, pregnancy, anticoagulant, thrombolytic and thrombectomy during 1990 to 2021.
Results: In this review article, finally 62 studies regarding pathophysiology, clinical feature, diagnostic strategies and treatment of pulmonary embolism during pregnancy were investigated.
Conclusion: The diagnosis of pulmonary embolism during pregnancy needs a high clinical suspicious. Due to the dangers of ionizing radiation to the fetus, correct using of diagnostic algorithms can reduce diminish radiation exposure to mother and fetus. Use of injectable anticoagulants such as enoxaparin is the main treatment method of pulmonary embolism during pregnancy. Oral anticoagulants are not recommended in pregnant women. Also, thrombolytic therapy and surgical thrombectomy can be used in the case of massive and life threatening pulmonary embolism.

Keywords

References

  1. Bourjeily G, Paidas M, Khalil H, Rosene-Montella K, Rodger M. Pulmonary embolism in pregnancy. The Lancet 2010;375(9713):500-12.
  2. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. The Lancet global health 2014;2(6):e323-33.
  3. Hashemi Petroudi I, Fanaei S, Dabbaghi B, Fazeli F, Nourkhomami S, Sedaghat A. Most Common reasons for ICU admissions during pregnancy in Asian mothers. Iran J Obstet Gynecol Infertil 2020;23(2):88-101.
  4. Dadipoor S, Mehraban M, Ziapour A, Safari Moradabadi A. Causes of maternal mortality in Iran: a systematic review. International journal of pediatrics; 2017.
  5. Pomp ER, Lenselink AM, Rosendaal FR, Doggen CJ. Pregnancy, the postpartum period and prothrombotic defects: risk of venous thrombosis in the MEGA study. Journal of Thrombosis and Haemostasis 2008;6(4):632-7.
  6. Heit JA, Kobbervig CE, James AH, Petterson TM, Bailey KR, Melton III LJ. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. Annals of internal medicine 2005;143(10):697-706.
  7. Jacobsen AF, Skjeldestad FE, Sandset PM. Incidence and risk patterns of venous thromboembolism in pregnancy and puerperium—a register-based case-control study. American journal of obstetrics and gynecology 2008;198(2):233-e1.
  8. Bates SM, Middeldorp S, Rodger M, James AH, Greer I. Guidance for the treatment and prevention of obstetric-associated venous thromboembolism. Journal of thrombosis and thrombolysis 2016;41(1):92-128.
  9. Turpie AG, Chin BS, Lip GY. Venous thromboembolism: pathophysiology, clinical features, and prevention. Bmj 2002;325(7369):887-90.
  10. Goulart VB, Cabral AC, Reis ZS, Navarro TP, Alves SL, de Miranda PR, et al. Anatomical and physiological changes in the venous system of lower limbs in pregnant women and findings associated with the symptomatology. Archives of gynecology and obstetrics 2013;288(1):73-8.
  11. Barbagallo M, Dominguez LJ, Licata G, Shan J, Bing L, Karpinski E, et al. Vascular effects of progesterone: role of cellular calcium regulation. Hypertension 2001;37(1):142-7.
  12. Boeldt DS, Bird IM. Vascular adaptation in pregnancy and endothelial dysfunction in preeclampsia. The Journal of endocrinology 2017;232(1):R27-44.
  13. Gerhardt A, Scharf RE, Greer IA, Zotz RB. Hereditary risk factors for thrombophilia and probability of venous thromboembolism during pregnancy and the puerperium. Blood, The Journal of the American Society of Hematology 2016;128(19):2343-9.
  14. Courtney DM, Kline JA, Kabrhel C, Moore CL, Smithline HA, Nordenholz KE, et al. Clinical features from the history and physical examination that predict the presence or absence of pulmonary embolism in symptomatic emergency department patients: results of a prospective, multicenter study. Annals of emergency medicine 2010;55(4):307-15.
  15. Heyl PS, Sappenfield WM, Burch D, Hernandez LE, Kavanaugh VM, Hill WC. Pregnancy-related deaths due to pulmonary embolism: findings from two state-based mortality reviews. Maternal and child health journal 2013;17(7):1230-5.
  16. Meng K, Hu X, Peng X, Zhang Z. Incidence of venous thromboembolism during pregnancy and the puerperium: a systematic review and meta-analysis. The Journal of Maternal-Fetal & Neonatal Medicine 2015;28(3):245-53.
  17. Pahade JK, Litmanovich D, Pedrosa I, Romero J, Bankier AA, Boiselle PM. Imaging pregnant patients with suspected pulmonary embolism: what the radiologist needs to know. Radiographics 2009;29(3):639-54.
  18. Dado CD, Levinson AT, Bourjeily G. Pregnancy and pulmonary embolism. Clinics in chest medicine 2018;39(3):525-37.
  19. Righini M, Van Es J, Den Exter PL, Roy PM, Verschuren F, Ghuysen A, et al. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. Jama 2014;311(11):1117-24.
  20. Kline JA, Williams GW, Hernandez-Nino J. D-dimer concentrations in normal pregnancy: new diagnostic thresholds are needed. Clinical chemistry 2005;51(5):825-9.
  21. Quiroz R, Schoepf UJ. CT pulmonary angiography for acute pulmonary embolism: cost-effectiveness analysis and review of the literature. InSeminars in roentgenology 2005; 40(1):20-24.
  22. Anderson DR, Kahn SR, Rodger MA, Kovacs MJ, Morris T, Hirsch A, et al. Computed tomographic pulmonary angiography vs ventilation-perfusion lung scanning in patients with suspected pulmonary embolism: a randomized controlled trial. Jama 2007;298(23):2743-53.
  23. Hurwitz LM, Yoshizumi T, Reiman RE, Goodman PC, Paulson EK, Frush DP, et al. Radiation dose to the fetus from body MDCT during early gestation. American Journal of Roentgenology 2006;186(3):871-6.
  24. Scarsbrook AF, Bradley KM, Gleeson FV. Perfusion scintigraphy: diagnostic utility in pregnant women with suspected pulmonary embolic disease. European radiology 2007;17(10):2554-60.
  25. Hogan S, Greene J, Flemming J. Rate of nondiagnostic computerized tomography pulmonary angiograms (CTPAs) performed for the diagnosis of pulmonary embolism in pregnant and immediately postpartum patients. Obstetrics and gynecology international 2019;2019.
  26. Yilmaz MH, Albayram S, Yasar D, Özer H, Adaletli I, Selçuk D, et al. Female breast radiation exposure during thorax multidetector computed tomography and the effectiveness of bismuth breast shield to reduce breast radiation dose. Journal of computer assisted tomography 2007;31(1):138-42.
  27. Doshi SK, Negus IS, Oduko JM. Fetal radiation dose from CT pulmonary angiography in late pregnancy: a phantom study. The British journal of radiology 2008;81(968):653-8.
  28. Matsunaga Y, Haba T, Kobayashi M, Suzuki S, Asada Y, Chida K. Fetal radiation dose of four tube voltages in abdominal CT examinations during pregnancy: A phantom study. Journal of applied clinical medical physics 2021;22(2):178-84.
  29. Yousefzadeh DK, Ward MB, Reft C. Internal barium shielding to minimize fetal irradiation in spiral chest CT: a phantom simulation experiment. Radiology 2006;239(3):751-8.
  30. Greer IA, Nelson-Piercy C. Low-molecular-weight heparins for thromboprophylaxis and treatment of venous thromboembolism in pregnancy: a systematic review of safety and efficacy. Blood 2005;106(2):401-7.
  31. Lepercq J, Conard J, Borel-Derlon A, Darmon JY, Boudignat O, Francoual C, et al. Venous thromboembolism during pregnancy: a retrospective study of enoxaparin safety in 624 pregnancies. British Journal of Obstetrics and Gynaecology 2001;108(11):1134-40.
  32. Crosby DA, McHugh A, Ryan K, Byrne B. Antenatal venous thromboembolism. The Obstetrician & Gynaecologist.
  33. Bates SM. Pregnancy-associated venous thromboembolism: prevention and treatment. InSeminars in hematology 2011; 48(4):271-84.
  34. Fasullo S, Maringhini G, Terrazzino G, Ganci F, Paterna S, Di Pasquale P. Thrombolysis for massive pulmonary embolism in pregnancy: a case report. International journal of emergency medicine 2011;4(1):1-6.
  35. Tawfik MM, Taman ME, Motawea AA, Abdel-Hady E. Thrombolysis for the management of massive pulmonary embolism in pregnancy. International journal of obstetric anesthesia 2013;22(2):149-52.
  36. Sousa Gomes M, Guimarães M, Montenegro N. Thrombolysis in pregnancy: a literature review. The Journal of Maternal-Fetal & Neonatal Medicine 2019;32(14):2418-28.
  37. Heavner MS, Zhang M, Bast CE, Parker L, Eyler RF. Thrombolysis for massive pulmonary embolism in pregnancy. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy 2017;37(11):1449-57.
  38. Martillotti G, Boehlen F, Robert‐Ebadi H, Jastrow N, Righini M, Blondon M. Treatment options for severe pulmonary embolism during pregnancy and the postpartum period: a systematic review. Journal of Thrombosis and Haemostasis 2017;15(10):1942-50.
  39. Pollack CV, Schreiber D, Goldhaber SZ, Slattery D, Fanikos J, O'Neil BJ, et al. Clinical characteristics, management, and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department: initial report of EMPEROR (Multicenter Emergency Medicine Pulmonary Embolism in the Real World Registry). Journal of the American College of Cardiology 2011; 57(6):700-706.
  40. Kline JA, Slattery D, O'Neil BJ, Thompson JR, Miller CD, Schreiber D, et al. Clinical features of patients with pulmonary embolism and a negative PERC rule result. Annals of emergency medicine 2013;61(1):122-4.
  41. Nicholson M, Khetani S, Rangasamy A. Almost Missed: Multiple Bilateral Pulmonary Emboli and Saddle Embolus Presenting as Syncope with No Other Signs of Pulmonary Embolism. InTP80. Tp080 Yellow Submarine-Pulmonary Emboli and other Case Reports 2021; A3494-A3494.
  42. Abbassi-Ghanavati M, Greer LG, Cunningham FG. Pregnancy and laboratory studies: a reference table for clinicians. Obstetrics & Gynecology 2009;114(6):1326-31.
  43. Schnittman SR, Byakwaga H, Boum Y, Kabakyenga J, Matthews LT, Burdo TH, et al. Changes in Immune Activation During Pregnancy and the Postpartum Period in Treated HIV Infection. InOpen forum infectious diseases 2021; 8(6):ofab245.
  44. Bourjeily G. D‐dimer use in venous thromboembolic disease in pregnancy. BJOG: An International Journal of Obstetrics & Gynaecology 2015;122(3):401-.
  45. Kruip MJ, Söhne M, Nijkeuter M, Kwakkel‐Van Erp HM, Tick LW, Halkes SJ, et al. A simple diagnostic strategy in hospitalized patients with clinically suspected pulmonary embolism. Journal of internal medicine 2006;260(5):459-66.
  46. Scarsbrook AF, Evans AL, Owen AR, Gleeson FV. Diagnosis of suspected venous thromboembolic disease in pregnancy. Clinical radiology 2006;61(1):1-12.
  47. Shahir K, Goodman LR, Tali A, Thorsen KM, Hellman RS. Pulmonary embolism in pregnancy: CT pulmonary angiography versus perfusion scanning. American journal of roentgenology 2010;195(3):W214-20.
  48. Astani SA, Davis LC, Harkness BA, Supanich MP, Dalal I. Detection of pulmonary embolism during pregnancy: comparing radiation doses of CTPA and pulmonary scintigraphy. Nuclear medicine communications 2014;35(7):704-11.
  49. Remy-Jardin M, Pistolesi M, Goodman LR, Gefter WB, Gottschalk A, Mayo JR, et al. Management of suspected acute pulmonary embolism in the era of CT angiography: a statement from the Fleischner Society. Radiology 2007;245(2):315-29.
  50. Stein PD, Terrin ML, Gottschalk A, Alavi A, Henry JW. Value of ventilation/perfusion scans versus perfusion scans alone in acute pulmonary embolism. The American journal of cardiology 1992;69(14):1239-41.
  51. Chatterson LC, Leswick DA, Fladeland DA, Hunt MM, Webster ST. Lead versus bismuth-antimony shield for fetal dose reduction at different gestational ages at CT pulmonary angiography. Radiology 2011;260(2):560-7.
  52. Kim YK, Sung YM, Choi JH, Kim EY, Kim HS. Reduced radiation exposure of the female breast during low-dose chest CT using organ-based tube current modulation and a bismuth shield: comparison of image quality and radiation dose. American Journal of Roentgenology 2013;200(3):537-44.
  53. Abadi S, Einarson A, Koren G. Use of warfarin during pregnancy. Canadian Family Physician 2002;48(4):695-7.
  54. Verma R, Tarun T, Enezate T, Bostick B, Que X. Mechanical Valve Thrombosis in Pregnancy-Patient Counseling Can Prevent Disaster. Journal of the American College of Cardiology 2021;77(18_Supplement_1):2837.
  55. Beyer‐Westendorf J, Marten S. Reproductive issues in women on direct oral anticoagulants. Research and Practice in Thrombosis and Haemostasis 2021;5(4):e12512.
  56. Tosounidou S, Gordon C. Medications in pregnancy and breastfeeding. Best Practice & Research Clinical Obstetrics & Gynaecology 2020;64:68-76.
  57. Patel S, Singh R, Preuss CV, Patel N. Warfarin. InStatPearls [Internet] 2020. StatPearls Publishing.
  58. Beyer-Westendorf J, Michalski F, Tittl L, Middeldorp S, Cohen H, Kadir RA, et al. Pregnancy outcome in patients exposed to direct oral anticoagulants-and the challenge of event reporting. Thrombosis and haemostasis 2016;116(10):651-8.
  59. Cohen H, Arachchillage DR, Middeldorp S, Beyer-Westendorf J, Abdul-Kadir R. Management of direct oral anticoagulants in women of childbearing potential: guidance from the SSC of the ISTH. J Thromb Haemost 2016;14(8):1673-6.
  60. Watanabe TT, Ichijo M, Kamata T. Uneventful pregnancy and delivery after thrombolysis plus thrombectomy for acute ischemic stroke: case study and literature review. Journal of Stroke and Cerebrovascular Diseases 2019;28(1):70-5.
  61. Tversky S, Libman RB, Reppucci ML, Tufano AM, Katz JM. Thrombolysis for ischemic stroke during pregnancy: a case report and review of the literature. Journal of Stroke and Cerebrovascular Diseases 2016;25(10):e167-70.
  62. Ritter LM, Schüler A, Gangopadhyay R, Mordecai L, Arowele O, Losseff N, et al. Successful thrombolysis of stroke with intravenous alteplase in the third trimester of pregnancy. Journal of neurology 2014; 261(3):632-4.
The Iranian Journal of Obstetrics, Gynecology and Infertility
Volume 24, Issue 7
September 2021
Pages 1-11

Files

Share

How to cite

Statistics