Successful low-dosage thrombolysis of massive pulmonary embolism in primigravida

Abstract

Rational:Thrombolysis in primigravida with hemodynamic instability is controversial, especially treatment with low-dosage recombinant tissue plasminogen activator (rtPA), and related studies are extremely rare. Here, we report the case of a 26-year-old primigravida diagnosed with an acute massive pulmonary embolism (PE) that prompted initiation of thrombolysis with low-dose alteplase.Patient concerns:The patient was admitted to the Emergency Department with chief complaints of a sudden onset of extremely dyspnea, chest tightness, and confusion over a 6-hour period. She was found to have significant dilation of her right ventricle, moderate pulmonary arterial hypotension, as shown by transthoracic echocardiography, and a typical S1-Q3-T3 pattern, as shown by electrocardiogram (ECG).Diagnosis:Acute massive PE in primigravida.Intervention:The patient underwent intravenous thrombolysis with a half dose of alteplase.Outcomes:The fetus lived through this severe event during the mother's stay in the Intensive Care Unit; however, surgical abortion was unexpectedly proposed due to long-term hypoxia and high-risk of relapse and exacerbation and was performed successfully after the agreement of her kin. The patient recovered gradually, and results of her laboratory tests and postsurgical, repeated contrast-enhanced computed tomography had normalized by her 3-month follow-up.Lessons:Administration of low-dosage alteplase in primigravida with hemodynamic instability is extremely rare and controversial; however, our case suggests that this treatment strategy is relatively safe and feasible. In addition, nonradiometric examination played a major role in the diagnosis of PE in this patient. Because radiation use is contraindicated during pregnancy, these examinations could be the first choice for pregnant patients with suspected PE.

Reduced-Dose Thrombolysis in Acute Pulmonary Embolism A Systematic Review

“…It is therefore not surprising that very low doses of thrombolytic therapy were effective in restoring pulmonary perfusion and preventing right heart collapse. 29,30 Highly reduced-dose thrombolysis for acute PE has been successfully used in high bleeding risk situations, for example, in post-surgical or pregnant patients, [31][32][33][34][35] indicating that the low-dose thrombolysis for PE is associated with reduced bleeding risk, while maintaining some efficacy in restoring pulmonary blood flow.…”