Thrombolytic therapy in pregnancy

Abstract

Pregnancy due to its physiological changes is a procoagulant state. The rate of cardiac valve prosthesis thrombosis, deep venous thrombosis and pulmonary embolism are all increased. Thrombolytic therapy with tissue plasminogen activator (rt-PA) is an approved therapy for ischemic stroke, myocardial infarction, pulmonary embolism and thrombosis of cardiac valve prosthesis. However, there are no data from controlled randomized trials in pregnant patients. Thrombolytic therapy has been rarely used in pregnancy with only 28 cases of rt-PA thrombolysis reported in the literature so far. Indications for rt-PA thrombolysis were stroke (n = 10), thrombosis of cardiac valve prosthesis (n = 7), pulmonary embolism (n = 7), deep venous thrombosis (n = 3), and myocardial infarction (n = 1). Remarkably, all thrombosis of cardiac valve prostheses occurred after switching from warfarin to heparin in order to prevent teratogenicity and fetal loss. Two patients died (7%) and three suffered from complications that were managed conservatively (11%). In another three patients thrombolysis was not successful. Thrombolysis complication rates were similar compared to non-pregnant patients for the above mentioned indications. Six out of the 26 fetus from surviving mothers died (23%), three of them after induced abortion for maternal reasons (12%). A likely causal relation to the prior thrombolysis could only be established in two fetal fatalities (8%). None of the live born children suffered a permanent deficit. Considering that rt-PA does not cross the placenta and taking into account that the complication rates do not exceed those of large randomised controlled trials thrombolytic therapy should not be withheld in pregnant patients in case of life-threatening or potentially debilitating thrombembolic disease.

Successful thrombolysis of aortic prosthetic valve thrombosis during first trimester of pregnancy

“…6,9 Spontaneous abortion rate (8-20%) associated with thrombolytic therapy is almost similar or only slightly higher than that in the general population. 2, 7 No permanent sequelae in surviving children have been reported. 7 There is an association between increasing lytic therapy complications and the severity of heart failure symptoms.…”

“…2, 7 No permanent sequelae in surviving children have been reported. 7 There is an association between increasing lytic therapy complications and the severity of heart failure symptoms. The overall mortality rate associated with lytic therapy is 9.9 to 10%, the highest rates are in NYHA class III and IV with 11.9% and 13%, respectively.…”

“…The rate of prosthetic valve thrombosis (incidence 4-14%), deep venous thrombosis and pulmonary embolism are increased. 7 For patients with a mechanical prosthetic valve, the incidence of thromboembolism during pregnancy is estimated from 7 to 23% with maximum episodes (50%) in the first trimester, as compared to 14% in the second trimester and 36 % in the third trimester; leading to maternal mortality of 2-15% in different clinical groups. 2,4, 6 The risk is increased due to the hypercoagulable state related to pregnancy, failure to continue Coumadin or due to switch-over to heparin.…”

A case of successful systemic thrombolysis in massive thromboembolia of pulmonary artery against the background of pregnancy

“…Клини-ческая оценка состояния больной и стратификация рис-ков по результатам объективных методов исследования явились основанием для тромболитической терапии. При выборе тактики лечения учитывали, что тканевые активаторы плазминогена не проникают через плаценту и не имеют тератогенного эффекта, а также что частота осложнений при данном методе лечения не превышает результаты крупных рандомизированных исследований в обычной популяции [7,10].…”

Massive Pulmonary Thromboembolism in Pregnancy Rescued Using Transcatheter Thrombectomy

“…4) Some mechanisms are also explained with Virchow's classic triad of factors underlying venous thrombosis; hypercoagulability, venous stasis, and vascular damage. 9) We therefore considered that resolving the pregnancy as soon as possible would be very important for improving the hypercoagulability stage and for recovery of her general condition.…”