SESSION TITLE: Pulmonary Vascular Disease Student/Resident Case Report Posters
SESSION TYPE: Student/Resident Case Report Poster
PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM
INTRODUCTION: The diagnosis and management of pulmonary embolism (PE) during pregnancy and in morbidly obese patients is challenging. We present a case of PE in an 11 weeks pregnant patient with a Body Mass Index of 75kg/mt2 that underwent successful thrombolysis and subsequent heparin.
CASE PRESENTATION: A morbidly obese 32yo female G2P0 who presented to the emergency department with shortness of breath after a syncopal episode. A transvaginal ultrasound (US) confirmed an 11 weeks intrauterine pregnancy. On exam she was tachycardic, and tachypneic. The electrocardiogram showed sinus tachycardia with S1Q3T3 pattern. D-Dimer level was 21.999ng/ml and Troponin was 1.02ng/ml. A Doppler US was negative for deep vein thrombosis. The CXR was normal. A VQ scan was performed revealing a large wedge shape defect on the right lung and absent perfusion of the left lung. A 2D echocardiogram demonstrated severe RV dysfunction with pulmonary arterial pressure (PAP) of 70mmHg and McConnell's sign. The patient remained stable, however, given the right ventricle (RV) dysfunction, positive troponin and clinical presentation, catheter directed thrombolysis was considered, however, was not possible due to her size, so intravenous alteplase 100mg was given. Her dyspnea resolved and the RV function improved dramatically with a repeat PAP of 40mmHg. She remained hospitalized on heparin drip. A trial of low molecular weight heparin was given, but the Anti-factor Xa activity after 4 hours was sub-therapeutic. Heparin drip was restarted and continued for the duration of the first trimester until warfarin was appropriate.
DISCUSSION: Venous thromboembolism is recognized as one of the most frequent causes of pregnancy-related deaths in the USA (19.6%). The diagnosis of PE in pregnancy is not easy considering the radiation exposure to the fetus and to the maternal breast tissue. The use of thrombolysis in PE has been proven to decrease all-cause mortality and hemodynamic collapse but there is limited data in pregnant patients. Low molecular weight heparin is the anticoagulation of choice during pregnancy because it does not cross the placenta; however it is unreliable in extreme obesity. Here we demonstrated the use of thrombolysis, heparin, and then warfarin when safe for the fetus, in a morbidly obese pregnant female with PE.
CONCLUSIONS: There is a paucity of data in regards to the use of thrombolysis during pregnancy and PE. Morbid obesity limits the choices of treatment of PE during the first trimester of pregnancy.
Reference #1: Rosenberg V, Lockwood C. Thromboembolism in Pregnancy. Obstet Gynecol Clin N Am. 34 (2007) 481-500.
Reference #2: Meyer G, et al. Fibrinolysis for Patients with Intermediate-Risk Pulmonary Embolism. NEJM. APR 2014. 370;15.
Reference #3: Cutts B, et al. New directions in the diagnosis and treatment of pulmonary embolism in pregnancy. American Journal of Obstetrics and Gynecology. FEB 2012. http://dx.doi.org/10.1016/j.ajog.2012.06.035
DISCLOSURE: The following authors have nothing to disclose: Gustavo Fernandez, Claudia Nieves, Katherine Melhado, Daniel Brito, Jean Bustamante, Samrat Khanna, Jorge Mora
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