Venous thromboembolism (VTE) remains to be the leading cause of maternal mortality. The management of pulmonary embolus (PE) in pregnancy is complicated by the lack of validated trials. The use of thrombolysis in pregnancy remains an experimental treatment, however, there are a number of case reports in the literature that suggest its use is safe for both the mother and the fetus. We report a case of successful use of recombinant tissue plasminogen activator (rt-PA) for the treatment of massive PE in a 28 year old woman who presented at 15 weeks of gestation with chest pain and collapse. A diagnosis was made with computed tomography pulmonary angiogram. The patient recovered with no complications however, at 22 weeks of gestation, went onto miscarry. This was believed to be as a result of infection and not related to the thrombolytic therapy.
Our literature review revealed 15 other reported cases of thrombolysis with rt-PA in pregnancy. There were no incidences of maternal death but 3 cases of fetal death, which were all believed to be unrelated to thrombolytic therapy. One case of minor bleeding complication was observed. These risks are acceptable in the light of the high risk of maternal death from a massive PE.
Although there is no licence for the use of thrombolysis in pregnancy, the reported cases suggest that it is an effective and safe option for the treatment of massive PE. We strongly support the idea of an international registry for those undergoing thrombolytic therapy in pregnancy.