Massive pulmonary embolism in pregnancy treated with catheter fragmentation and local thrombolysis

BACKGROUND: Catheter-directed thromboembolus fragmentation and thrombolysis is used with success for treatment of pulmonary embolism with hemodynamic decompensation in nonpregnant patients, but information on its use during pregnancy is limited. We report successful treatment of massive bilateral pulmonary emboli in the third trimester of pregnancy. CASE: A 29-year-old multigravida at 30 weeks of gestation presented with dyspnea, chest pain, heart palpitations, and syncope. A computed tomographic angiogram demonstrated massive bilateral central pulmonary emboli. Despite heparin and oxygen therapy, aggressive fluid resuscitation and pressor treatment, hypotension persisted, and there were prolonged, deep fetal heart rate decelerations. Emergency percutaneous pulmonary artery catheter thrombus fragmentation, followed by local infusion of tissue plasminogen activator, was performed. The patient recovered rapidly and was discharged from the hospital on subcutaneous low-molecular-weight heparin. She was delivered of a normal, healthy infant at term. CONCLUSION: Catheter-directed mechanical fragmentation and local thrombolytic infusion therapy is a treatment option for pulmonary embolism with hemodynamic decompensation in pregnancy. Advantages are rapid clot lysis with consequent return of normal hemodynamics and uterine perfusion and avoidance of systemic thrombolytics and associated risk of bleeding complications.