Anticoagulant therapy for venous thromboembolism during pregnancy: a systematic review and a meta-analysis of the literature: a reply to a rebuttal

Successful low-dosage thrombolysis of massive pulmonary embolism in primigravida: A case report

RATIONAL

Thrombolysis in primigravida with hemodynamic instability is controversial, especially treatment with low-dosage recombinant tissue plasminogen activator (rtPA), and related studies are extremely rare. Here, we report the case of a 26-year-old primigravida diagnosed with an acute massive pulmonary embolism (PE) that prompted initiation of thrombolysis with low-dose alteplase.

PATIENT CONCERNS

The patient was admitted to the Emergency Department with chief complaints of a sudden onset of extremely dyspnea, chest tightness, and confusion over a 6-hour period. She was found to have significant dilation of her right ventricle, moderate pulmonary arterial hypotension, as shown by transthoracic echocardiography, and a typical S1-Q3-T3 pattern, as shown by electrocardiogram (ECG).

DIAGNOSIS

Acute massive PE in primigravida.

INTERVENTION

The patient underwent intravenous thrombolysis with a half dose of alteplase.

OUTCOMES

The fetus lived through this severe event during the mother's stay in the Intensive Care Unit; however, surgical abortion was unexpectedly proposed due to long-term hypoxia and high-risk of relapse and exacerbation and was performed successfully after the agreement of her kin. The patient recovered gradually, and results of her laboratory tests and postsurgical, repeated contrast-enhanced computed tomography had normalized by her 3-month follow-up.

LESSONS

Administration of low-dosage alteplase in primigravida with hemodynamic instability is extremely rare and controversial; however, our case suggests that this treatment strategy is relatively safe and feasible. In addition, nonradiometric examination played a major role in the diagnosis of PE in this patient. Because radiation use is contraindicated during pregnancy, these examinations could be the first choice for pregnant patients with suspected PE.

Adjustment of therapeutic LMWH to achieve specific target anti-FXa activity does not affect outcomes in pregnant patients with venous thromboembolism

Venous thromboembolism (VTE) remains a leading cause of maternal morbidity and mortality in the developed world. Low molecular weight heparins (LMWH) are routinely used to provide therapeutic anticoagulation during pregnancy for women with VTE, with measurement of plasma anti-FXa activity used to guide dosing in certain patient groups. There is limited evidence to support the use of anti-FXa monitoring in pregnant patients. This study seeks to ascertain whether anti-FXa monitoring of pregnant patients with VTE influences patient outcomes. We performed a single-centre case series including two consecutive groups of pregnant patients treated with LMWH for VTE sustained in the index pregnancy with and without monitoring of anti-FXa levels. 35,394 patients delivered during the study period in a large urban stand-alone maternity hospital, with 26 cases of VTE eligible for inclusion. There was no significant difference between the two groups in any clinical outcome; including maternal blood loss at delivery, recurrent thromboembolic events or rates of planned delivery. These data provide clinical evidence to support current international guideline recommendations that measurement of plasma anti-FXa activity in the majority of patients receiving therapeutic-intensity antenatal LMWH is not warranted.

Pharmacological management of pulmonary embolism

INTRODUCTION

Pulmonary embolism (PE) is a common and potentially severe manifestation of venous thromboembolism. Its management has relied on anticoagulation by vitamin K antagonists (VKA) for the past fifty years. Recently, new alternative drugs have been developed and dramatically modified both the treatment of acute PE and its secondary prevention. Areas covered: This review discusses the contemporary pharmacological treatment for PE, with a focus on anticoagulation options for non-high risk PE. In particular, the advent of direct oral anticoagulants (rivaroxaban, apixaban, edoxaban and dabigatran) and modalities for long-term prevention will be described. Options for anticoagulation for pregnancy-related PE are presented separately. Expert opinion: Direct oral anticoagulants represent the first-line therapy of non-high risk PE, with better risk-benefit ratios compared with VKA due to lower bleeding risks. In specific groups of patients, however, older generations of anticoagulants such as VKA or heparins still play an important role. Multiple alternatives are available for the secondary prevention of PE, with different efficacies in reducing thrombotic risk and bleeding safety profiles.