Fatality rates and use of systemic thrombolysis in pregnant women with pulmonary embolism.
Hobohm L, Keller K, Valerio L, Ni Ainle F, Klok FA, Münzel T, Kucher N, Lankeit M, Konstantinides SV, Barco S.ESC Heart Fail. 2020 Oct;7(5):2365-2372. doi: 10.1002/ehf2.12775. Epub 2020 Jun 21.PMID: 32567197 Free PMC article.
Take Home Points:
- Pulmonary embolism has a high mortality rate in pregnant women.
- Even with thrombolysis once there is haemodynamic compromise there were very high mortality rates.
- Pulmonary embolism is a common problem pregnancy, complicating 2.2 cases per 10,000 pregnancies and represents 14% of all maternal deaths.
Commentary from Dr. Reza Ashrafi (Liverpool, United Kingdom), section editor of Cardio-Obstetrics Journal Watch:
Methods
A retrospective analysis of 11 years’ worth of inpatient data from the German national inpatient registry. All pregnant patients were analysed and identified if they had been coded for pulmonary embolism (PE) or obstetric thromboembolism. Administrative data records were then reviewed for management and outcomes from the embolism or thromboembolic event including haemodynamic failure, thrombolysis and maternal death.
Results
Over an 11 year period there 8,271,327 livebirths and 1846 hospitalisations with pregnancy associated pulmonary embolism with a median maternal age of 31. Median inpatient stay was 8 days. Overall there was a downward trend in the incidence and mortality of PE during the timeframe of the study (Figure 1).
There was a significant increase in the incidence of PE in the final 4 weeks of pregnancy and in patients who had surgery during their in-hospital stay.
Of 151 women with haemodynamic failure and PE only 51 received thrombolysis with a trend towards use either early in pregnancy or in the final 4 weeks. There was a trend towards an increase in the odds of death in patients receiving thrombolysis (age adjusted odds ratio 3.48).
Discussion
Whilst the study is limited by the retrospective nature of the data and the fact it is based on administrative data it does identify the continuing high mortality risk of PE in pregnancy. Once haemodynamic deterioration sets in, thrombolysis is only partially effective as evidenced by the high in-hospital mortality in the thrombolysis group of 43%.
Given the lack of data at a patient level available to the authors it is not possible to suggest thrombolysis is under or overused or that it is clearly associated with worse outcomes only that it requires more research.
More work is needed in identification and prevention for PE before haemodynamic failure occurs.
