High-risk pulmonary embolism in pregnancy
Shilova A.S., Ketskalo M.V., Ploshchenkov E.V., Raimov M.B., Vachnadze D.I., Troitsky D.A., Samostrol N.T., Rozina N.A., Gilyarova E.M., Georgiev R.A., Salamov R.S., Chernikov A.O.
Pulmonary embolism (PE) is one of the leading causes of maternal mortality worldwide. Treatment of PE in pregnancy and early postpartum is significantly complicated by high risk of bleeding, changes in hemostasis and hemodynamics, and fetal factors. Thrombolysis is the preferable method of reperfusion therapy in life threatening PE in pregnancy, but it is associated with extremely high risk of bleeding in early postpartum period. Therefore, it is necessary to find alternative methods of pulmonary artery reperfusion and stabilization using modern techniques of mechanical circulatory support. The data on the use of endovascular treatment and venoarterial extracorporeal membrane oxygenation (VA-ECMO) in PE in pregnant and postpartum women are extremely limited. This article presents a review of the latest technologies in the treatment of high-risk PE in pregnant women based on the clinical observation of the intensive care unit patients with myocardial infarction at N.I. Pirogov City Clinical Hospital No.1, Moscow City Health Department, Moscow.
Conclusion: An important question that needs to be addressed is when the use of ECMO in patients with PE, even during pregnancy, should be considered. Based on the available experience in the modern world, there are the following main indications: circulatory arrest, refractory cardiogenic obstructive shock, especially when reperfusion therapy is contraindicated or associated with a high risk of bleeding (early after caesarean section, thrombolytic therapy).
Authors' contributions: Shilova A.S. – literature review, general editing; Ketskalo M.V. – concept and design of the work, general editing; Ploshchenkov E.V., Gilyarova E.M. – editing; Raimov M.B., Rozina N.A. – literature review; Vachnadze D.I. – literature review, writing the text; Troitskiy D.A., Georgiev R.A., Chernikov A.O. – writing the text; Samostrol N.T. – collection and statistical processing of material.
Conflicts of interest: The authors declare no possible conflicts of interest.
Funding: The study was conducted without sponsorship.
Patient Consent for Publication: The patient provided informed consent for the publication of her data and associated images.
For citation: Shilova A.S., Ketskalo M.V., Ploshchenkov E.V., Raimov M.B., Vachnadze D.I., Troitskiy D.A.,
Samostrol N.T., Rozina N.A., Gilyarova E.M., Georgiev R.A., Salamov R.S., Chernikov A.O.
High-risk pulmonary embolism in pregnancy.
Akusherstvo i Ginekologiya/Obstetrics and Gynecology. 2025; (1): 118-126 (in Russian)
https://dx.doi.org/10.18565/aig.2024.239
Keywords
pulmonary embolism
PE
PE in pregnancy
thrombolysis
extracorporeal membrane oxygenation
ECMO
References
- Warren B.B., Moyer G.C., Manco-Johnson M.J. Hemostasis in the pregnant woman, the placenta, the fetus, and the newborn infant. Semin. Thromb. Hemost. 2023; 49(4): 319-29. https://dx.doi.org/10.1055/s-0042-1760332.
- Schapkaitz E., Libhaber E., Gerber A., Rhemtula H., Zamparini J., Jacobson B.F. et al. A longitudinal study of thrombosis and bleeding outcomes with thromboprophylaxis in pregnant women at intermediate and high risk of VTE. Clin. Appl. Thromb. Hemost. 2023; 29: 10760296231160748. https://dx.doi.org/10.1177/10760296231160748.
- Henriksson P., Westerlund E., Wallén H., Brandt L., Hovatta O., Ekbom A. Incidence of pulmonary and venous thromboembolism in pregnancies after in vitro fertilisation: cross sectional study. BMJ. 2013; 346: e8632. https://dx.doi.org/10.1136/bmj.e8632.
- Maughan B.C., Marin M., Han J., Gibbins K.J., Brixey A.G., Caughey A.B. et al. Venous thromboembolism during pregnancy and the postpartum period: risk factors, diagnostic testing, and treatment. Obstet. Gynecol. Surv. 2022; 77(7): 433-44. https://dx.doi.org/10.1097/OGX.0000000000001043.
- Zuin M., Rigatelli G., Temporelli P., Bilato C. Trends in mortality related to venous thromboembolism in the European Union, 2012-2020. Intern. Emerg. Med. 2024; 19(4): 941-9. https://dx.doi.org/10.1007/s11739-024-03550-6.
- Konstantinides S.V., Meyer G., Becattini C., Bueno H., Geersing G.J., Harjola V.P. et al.; ESC Scientific Document Group. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur. Heart J. 2020; 41(4): 543-603. https://dx.doi.org/10.1093/eurheartj/ehz405.
- Hobohm L., Keller K., Valerio L., Ni Ainle F., Klok F.A., Münzel T. et al. Fatality rates and use of systemic thrombolysis in pregnant women with pulmonary embolism. ESC Heart Fail. 2020; 7(5): 2365-72. https://dx.doi.org/10.1002/ehf2.12775.
- Martillotti G., Boehlen F., Robert-Ebadi H., Jastrow N., Righini M., Blondon M. Treatment options for severe pulmonary embolism during pregnancy and the postpartum period: a systematic review. J. Thromb. Haemost. 2017; 15(10): 1942-50. https://dx.doi.org/10.1111/jth.13802.
- Wan T., Skeith L., Karovitch A., Rodger M., Le Gal G. Guidance for the diagnosis of pulmonary embolism during pregnancy: Consensus and controversies. Thromb. Res. 2017; 157: 23-8. https://dx.doi.org/10.1016/j.thromres.2017.06.025.
- Varrias D., Spanos M., Kokkinidis D.G., Zoumpourlis P., Kalaitzopoulos D.R. Venous thromboembolism in pregnancy: challenges and solutions. Vasc. Health Risk Manag. 2023; 19: 469-84. https://dx.doi.org/10.2147/VHRM.S404537.
- Fitzsimmons J., Hart L., Oliver E., Mulla W. Diagnosis of pulmonary embolism in pregnancy. Am. J. Perinatol. 2024; 41(S 01): e2307-e2312. https://dx.doi.org/10.1055/a-2112-8049.
- van der Pol L.M., Tromeur C., Bistervels I.M., Ni Ainle F., van Bemmel T., Bertoletti L. et al.; Artemis Study Investigators. Pregnancy-adapted YEARS algorithm for diagnosis of suspected pulmonary embolism. N. Engl. J. Med. 2019; 380(12): 1139-49. https://dx.doi.org/10.1056/NEJMoa1813865.
- Министерство здравоохранения Российской Федерации. Клинические рекомендации. Венозные осложнения во время беременности и послеродовом периоде. Акушерская тромбоэмболия. 2024. 99 с. [Ministry of Health of the Russian Federation. Clinical guidelines. Venous complications during pregnancy and postpartum. Obstetric thromboembolism. 2024. 99 p. (in Russian)].
- Sousa Gomes M., Guimarães M., Montenegro N. Thrombolysis in pregnancy: a literature review J. Matern. Fetal Neonatal. Med. 2019; 32(14): 2418-28. https://dx.doi.org/10.1080/14767058.2018.1434141.
- Sanchez O., Charles-Nelson A., Ageno W., Barco S., Binder H., Chatellier G. et al.; PEITHO-3 Investigators. Reduced-dose intravenous thrombolysis for acute intermediate-high-risk pulmonary embolism: rationale and design of the pulmonary embolism international THrOmbolysis (PEITHO)-3 trial. Thromb. Haemost. 2022; 122(5): 857-66. https://dx.doi.org/10.1055/a-1653-4699.
- Meneveau N., Guillon B., Planquette B., Piton G., Kimmoun A., Gaide-Chevronnay L. et al. Outcomes after extracorporeal membrane oxygenation for the treatment of high-risk pulmonary embolism: a multicentre series of 52 cases. Eur. Heart J. 2018; 39(47): 4196-4204. https://dx.doi.org/10.1093/eurheartj/ehy464.
- Webster L.A., Bishay V. Venous thromboembolism management in pregnant patients. Tech. Vasc. Interv. Radiol. 2023; 26(2): 100901. https://dx.doi.org/10.1016/j.tvir.2023.100901.
- Webster C.M., Smith K.A., Manuck T.A. Extracorporeal membrane oxygenation in pregnant and postpartum women: a ten-year case series Am. J. Obstet. Gynecol. MFM. 2020; 2(2): 100108. https://dx.doi.org/10.1016/j.ajogmf.2020.100108.
- Ong J., Zhang J.J.Y., Lorusso R., MacLaren G., Ramanathan K. Extracorporeal membrane oxygenation in pregnancy and the postpartum period: a systematic review of case reports Int. J. Obstet. Anesth. 2020; 43: 106-13. https://dx.doi.org/10.1016/j.ijoa.2020.04.004.
- Naoum E.E., Chalupka A., Haft J., MacEachern M., Vandeven C.J.M., Easter S.R. et al. Extracorporeal life support in pregnancy: a systematic review. J. Am. Heart Assoc. 2020; 9(13): e016072. https://dx.doi.org/10.1161/JAHA.119.016072.
- Sebastian N.A., Spence A.R., Bouhadoun S., Abenhaim H.A. Extracorporeal membrane oxygenation in pregnant and postpartum patients: a systematic review. J. Matern. Fetal Neonatal. Med. 2022; 35(24): 4663-73. https://dx.doi.org/10.1080/14767058.2020.1860932.
- Agerstrand C., Abrams D., Biscotti M., Moroz L., Rosenzweig E.B., D'Alton M. et al. Extracorporeal membrane oxygenation for cardiopulmonary failure during pregnancy and postpartum. Ann. Thorac. Surg. 2016; 102(3): 774-9. https://dx.doi.org/10.1016/j.athoracsur.2016.03.005.
- https://www.karolinska.se/globalassets/global/4-gamla-kataloger/tema-barn-och-kvinnosjukvard/ecmo/beslutsstod-for-ecmo-behandling.pdf
- Яворовский А.Г., ред. Экстракорпоральная мембранная оксигенация при лечении критической сердечной и дыхательной недостаточности. Практическое руководство. М.: ГЭОТАР-Медиа; 2024. 176 с. [Yavorovsky A.G., ed. Extracorporeal membrane oxygenation in the treatment of critical heart and respiratory failure. Practical guide. Moscow: GEOTAR-Media; 2024. 176 p. (in Russian)].
- Olson S.R., Murphree C.R., Zonies D., Meyer A.D., Mccarty O.J.T., Deloughery T.G. et al. Thrombosis and bleeding in extracorporeal membrane oxygenation (ECMO) without anticoagulation: a systematic review. ASAIO J. 2021; 67(3): 290-6. https://dx.doi.org/10.1097/MAT.0000000000001230.
- Melchiorre K., Sharma R., Khalil A., Thilaganathan B. Maternal cardiovascular function in normal pregnancy: evidence of maladaptation to chronic volume overload. Hypertension. 2016; 67(4): 754-62. https://dx.doi.org/10.1161/HYPERTENSIONAHA.115.06667.
Received 10.10.2024
Accepted 25.12.2024
About the Authors
Aleksandra S. Shilova, PhD, Head of the Regional Vascular Center, N.I. Pirogov City Clinical Hospital No. 1, 119049, Russia, Moscow, Leninskiy Ave., 8, +7(903)559-40-90, a.s.shilova@gmail.com, https://orcid.org/0000-0002-4092-5222Mikhail V. Ketskalo, PhD, Director of the NMRC for Anesthesiology and Resuscitation (for pregnant women), V.I. Kulakov NMRC for OG&P, Ministry of Health of Russia, 117997, Russia, Moscow, Ac. Oparin str., 4, +7(926)352-90-73, m_ketskalo@oparina4.ru, https://orcid.org/0000-0001-6569-2106
Evgeniy V. Ploshchenkov, Head of the Department of X-ray Surgical Methods of Diagnosis and Treatment No. 1, N.I. Pirogov City Clinical Hospital No. 1,
119049, Russia, Moscow, Leninskiy Ave., 8, +7(985)252-60-66, Jenya-09@inbox.ru, https://orcid.org/0009-0007-4694-6140
Murat B. Raimov, Anesthesiologist & Intensive Care Specialist, Head of the ICU Department for patients with acute myocardial infarction, N.I. Pirogov City Clinical Hospital No. 1, 119049, Russia, Moscow, Leninskiy Ave., 8, +7(999)817-48-21, mraimov@gmail.com, https://orcid.org/0009-0007-4952-4015
David I. Vachnadze, Anesthesiologist & Intensive Care Specialist, ICU Department for patients with acute myocardial infarction, N.I. Pirogov City Clinical Hospital No. 1, 119049, Russia, Moscow, Leninskiy Ave., 8, dr@vachnadze.ru, https://orcid.org/0000-0003-0482-3795
Daniil A. Troitskiy, Anesthesiologist & Intensive Care Specialist, ICU Department for patients with acute myocardial infarction, N.I. Pirogov City Clinical Hospital No. 1, 119049, Russia, Moscow, Leninskiy Ave., 8, +7(915)178-16-56, troickijd@gmail.com, https://orcid.org/0000-0002-1181-518X
Natalia T. Samostrol, Anesthesiologist & Intensive Care Specialist, ICU Department for patients with acute myocardial infarction, N.I. Pirogov City Clinical Hospital No. 1, 119049, Russia, Moscow, Leninskiy Ave., 8, +7(985)292-01-51, Samostrol1992@gmail.com, https://orcid.org/0009-0002-7297-6638
Nina A. Rozina, Anesthesiologist & Intensive Care Specialist, ICU Department for patients with acute myocardial infarction, N.I. Pirogov City Clinical Hospital No. 1,
119049, Russia, Moscow, Leninskiy Ave., 8, +7(915)207-10-49, rozina.nina@gmail.com, https://orcid.org/0000-0002-0577-633X
Ekaterina M. Gilyarova, Cardiologist, ICU Department for patients with acute myocardial infarction, N.I. Pirogov City Clinical Hospital No. 1, 119049, Russia, Moscow, Leninskiy Ave., 8, +7(916)833-62-20, gilarovae@gmail.com, https://orcid.org/0000-0002-5598-855X
Roman A. Georgiev, Interventional Cardiologist, Department of X-ray Surgical Methods of Diagnosis and Treatment No. 1, N.I. Pirogov City Clinical Hospital No. 1,
119049, Russia, Moscow, Leninskiy Ave., 8, +7(905)027-63-57, georgievra@gmail.com, https://orcid.org/0009-0002-2872-2497
Artem O. Chernikov, Cardiologist, ICU Department for patients with acute myocardial infarction, N.I. Pirogov City Clinical Hospital No. 1, 119049, Russia, Moscow,
Leninskiy Ave., 8, chernikovtema@mail.ru, https://orcid.org/0009-0000-0492-9878
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