This document presents a case study of a 32-year-old pregnant woman in her 16th week of gestation who was diagnosed with massive pulmonary embolism. She was treated with recombinant tissue plasminogen activator thrombolytic therapy, which resulted in an excellent response with dramatic improvement in her respiratory status and normalization of her heart rate and blood pressure without hemorrhagic complications. Follow-up exams showed normalization of her right ventricular function. She gave birth to a healthy child at term. The conclusion is that early thrombolytic therapy should be considered for unstable pregnant patients with massive pulmonary embolism.

1. CARDIAC PROBLEMS
IN PREGNANCY
LAS VEGAS, NEVADA, USA
27 February – 1 March 2016

2. SUCCESSFUL TREATMENT
WITH RECOMBINANT TISSUE
PLASMINOGEN ACTIVATOR OF
MASSIVE PULMONARY EMBOLISM
IN THE 16TH WEEK OF PREGNANCY
Daniel B. Petrov, MD
Maria H. Milanova. MD, PhD
Adelina Peneva, MD
Emergency Hospital “Pirogov”, Sofia, Bulgaria

3. BACKGROUND
Thrombolytic agents have been
used successfully to treat
patients with massive
pulmonary embolism, but
experience with these drugs in
pregnancy is limited.

4. OBJECTIVE
The aim of this study is to
present the case of massive
pulmonary embolism in a
pregnant woman with an
excellent response to early
thrombolytic therapy.

5. CASE PRESENTATION
We report a 32-year-old pregnant
female, who was at 16th week of
gestation, presented with acute
collapse and progressive dyspnea
over a few days. No risk factors
were present in the patient’s
clinical history.

6. CASE PRESENTATION
On physical examination, she had
tachypnoea with respiratory rate of
30 per minute, hypotension (blood
pressure 80/40 mmHg) and
tachycardia (133 beats per minute).
Laboratory evaluation was
remarkable for D-dimer 3254
(normal < 234) and cardiac troponin
0.34 ng/ml (normal < 0.06).

7. CASE PRESENTATION
The electrocardiogram (ECG)
was notable for sinus
tachycardia with a rate of 133
per minute, right axis deviation
(deep S wave in lead I), and T
wave inversion in leads V1-V4
(Fig 1).

8. Case 2
Admission ECG showed sinus tachycardia, deep S
wave in lead I and T wave inversion in leads V1 – V4.

9. CASE PRESENTATION
The clinical presentation was
highly suggestive of an acute PE,
and intravenous heparin was
started immediately. Doppler
studies of legs showed bilateral
proximal deep venous thrombosis,
making the diagnosis of PE likely.

10. CASE PRESENTATION
The diagnosis was rapidly confirmed in the
ED with two-dimensional-Doppler echo-
cardiography that demonstrated signs of right
ventricular dysfunction (the right ventricle was
enlarged, hypokinetic and severe tricuspid
regurgitation was present) and pulmonary
hypertension (systolic pulmonary-artery
pressure of 67 mmHg) as well as direct
visualization of large thrombus at the
bifurcation of the main pulmonary artery
(Fig 2) .

11. Transthoracic echocardiography revealed a large saddle
thrombus at the bifurcation of the main pulmonary artery.

12. Because of significant haemodynamic
instability and no improvement after
intravenous heparin, the patient was
treated with recombinant tissue
plasminogen activator 100 mg over 2
hours with subsequent heparin infusion
for 48 hours, when LMWH
(enoxaparin) was started.
CASE PRESENTATION

13. The response to fibrinolytic therapy was
excellent without haemorrhagic
complications. Her respiratory status
dramatically improved and the heart
rate and blood pressure normalized.
Serial ECGs demonstrated that the main
QRS axis returned to normal with
reduction of the S wave amplitude in
lead I (Fig 3).
CASE PRESENTATION

14. Case 2
The ECG after fibrinolysis showed reduction of the S
wave in lead I and slowing down of the heart rate.

15. Repeated echocardiogram
performed 24 hours later showed
that right ventricular systolic
pressure decreased to 36 mmHg
and right ventricular function and
dimension returned to normal
limits. Ultrasound scan revealed no
signs of placental or fetal bleeding.
CASE PRESENTATION

16. On follow-up 6 weeks later, the
patient’s condition was good and
echocardiogram documented
normal right ventricular function.
LMWH was continued until
delivery, and a healthy child was
born at term.
CASE PRESENTATION

17. Based on our case and on what has
been previously described in the
literature, early thrombolytic
therapy should be considered as an
option in the management of
unstable pregnant patients with
massive pulmonary embolism.
CONCLUSION

18. Acknowledgements
This study was supported by
the pharmaceutical company
BOEHRINGER INGELHEIM.