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Three Part Question

[In a pregnant patient with pulmonary embolism][does giving thrombolysis][help reduce the mortality]

Clinical Scenario

a 24 weeks pregnant women comes to the A&E dept with sudden haemodynamic collapse(hypotensive/tachycardic & hypoxic), She has no previous medical history and the pregnancy has been uneventful so far. You find a rt sided swollen,erythematous and tender rt lower limb suggestive of DVT. You wonder whether thrombolysis will help this lady improve her clinical outcome from PE

Search Strategy

OVID Medline 1950 to April 2007
Cochrane search
Embase search
CINHAL
exp pregnancy complications,hematologic/ or exp pregnancy complications/ or pregnancy.mp. or exp pregnancy/ or exp pregnancy complications cardiovascular/pregnan$.mp./gravid$.mp.exp pulmonary embolism/exp pulmonary embolism/pulmonary embol$.mp./thromboembol$.mp./PE.mp./lung clot.mp/exp fibrinolytic agents/ or exp thrombolytic therapy/ or tissue plasminogenactivator/reteplase.mp./tenecteplase.mp./apsac.mp. or exp anistreplase/(thromboly$ or fibrinoly$ or reteplase or streptokinase or tenecteplase or alteplase).mp/exp fibrinolytic therapy/exp thrombolytic therapy/

Search Outcome

254 papers were found but only 9 were relevant.
All the papers were either case reports or review articles

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
P K Mazeika 1994 London,UK	34 years old,24 weeks pregnant patient with PE, first pregnancy,	case report	safe thrombolysis	mother and child safe	level 5 evidence
M de Sweit 1999 London,UK	pregnant patients with pulmonary embolism	review article	thrombolysis recommended in pregnant PE patients with haemodynamic instability		evidence based on case series
G S Ahearn 2002 USA	24 yrs old pregnant patient with haemodynamic unstability,12 weeks duration	case report and review article	mother and child saved		grade 5 evidence
A T Marty 2004 USA	post cesarean section pulmonary embolism treated with surgical embolectomy	case report	patient survived		level 5 evidence
I A Greer 2005 Glasgow UK	pregnant patients with thromboembolism	review article			PE patients with haemodynamic upset were'nt reviewed
M Gujrar 2005 India	25 yrs old ,one post ceaserian section, haemodynamically unstable thromboembolism, treated with thrombolysis	case report	patient survived
G Leonheart 2006 Netherlands	thrombolysis in pregnant patient with ischaemic stroke	review article and case report	patient survived and recovered

Comment(s)

Thrombolytic therapy for pulmonary embolism in pregnancy has been found to be safe for both maternal and foetal cases but the evidence is based on case reports only.

Clinical Bottom Line

Thrombolytic therapy for pulmonary embolism during pregnancy can be only considered for cases with haemodynamic instability and expert advice has to be considered at present on case by case basis till further research is carried out.

References

1. P Mazeika European Heart Journal
2. M de Swiet European heart Journal
3. L B Yap international journal of cardiology
4. G S Ahearn Archives of internal medicine
5. A T Marty American college of O & G
6. Prof I A Greer Gender Medicine
7. M Gujrar indian journal of medicine
8. G Leonheart J Throm Thrombolysis