Pulmonary embolism in pregnancy and covid

1. Pulmonary Embolism in
Pregnancy

2. Acute Pulmonary Embolism in Pregnancy
• Acute pulmonary embolism (PE) remains one of the primary drivers of maternal mortality. During
pregnancy and puerperium, the risk of coagulation increases.
• Venous stasis and hypervolemia, together with endothelial injury and changes at the uteroplacental surface
at the time of delivery, all contribute to a higher risk of acute PE.
• The diagnostic management of PE in pregnancy is particularly challenging due to the fact that pregnant
women often have clinical symptoms, such as shortness of breath or tachycardia, which could point to the
suspicion of PE, but can also be present as physiological changes during pregnancy.
Elgendy, Islam Y., et al. "Acute pulmonary embolism during pregnancy and puerperium: national trends and in-hospital outcomes." Mayo Clinic Proceedings.
Vol. 96. No. 8. Elsevier, 2021.

3. Acute Pulmonary Embolism in Pregnancy
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Orfanoudaki, I. M. "Review article: pulmonary embolism in pregnancy: suspicion, diagnosis and therapy." Obstet Gynecol Int J 10.1 (2019): 1-13.

4. Acute Pulmonary Embolism in Pregnancy
• The physical and hormonal changes associated in pregnancy contribute in hyper coagulation in
pregnant women
• Hormonal factors produce stasis of blood which leads to venodilation of pregnancy. An increased stasis
is produced by progesterone levels which are elevated at the starting of pregnancy, and produce
venous distensibility and capacity.
• As pregnancy goes on, the uterus which enlarges compress the common iliac vein. The significant
venous stasis is observed more common in the left deep system because the right iliac artery
compresses the left common iliac vein
• During this venous stasis, thrombi originate in venous valve pockets. Most common these thrombi
(emboli) can arise from deep venous system, rarely from right heart chambers or other veins. But,
they can originate from any part in the body.
• These emboli, travel with blood and reach to the cavities of the heart, right atrium, right ventricle,
left atrium, left ventricle and finally to the lungs.
• In the lungs, if emboli are massive, they produce hemodymamic compromise because the lodge at
the bifurcation of the main pulmonary artery of the lobar branches.
• When thrombi are smaller, they are able to travel far away and occlude the smaller vessels in the
periphery of the lungs. A pleuritic chest pain is present due to an inflammatory response of parietal
pleura. The emboli mostly are multiple and are often to the upper lobes of the lungs
ETIOLOGY
Orfanoudaki, I. M. "Review article: pulmonary embolism in
pregnancy: suspicion, diagnosis and therapy." Obstet Gyneco
Int J 10.1 (2019): 1-13.

5. Acute Pulmonary Embolism in Pregnancy
ACUTE PULMONARY EMBOLISM WITH HEMODYNAMIC INSTABILITY
• All patients with suspected PE and signs of haemodynamic compromise have a high-risk of death during the first hours and
days. Thus, initiation of heparin anticoagulation is recommended without delay in patients with high or intermediate clinical
probability of PE, while diagnostic workup is in progress.
• The recent published European Society of Cardiology (ESC) guidelines for the diagnosis and management of acute PE underline
the importance of a bedside transthoracic echocardiography (TTE) examination in patients with haemodynamic instability.
Acute right ventricular (RV) dysfunction can rapidly be detected by TTE if acute PE is the cause of patient’s haemodynamic
deterioration.
• If no signs of RV dysfunction exist, other causes of haemodynamic deterioration such as cardiac tamponade, acute coronary
syndrome, aortic dissection, acute valvular dysfunction and/or hypovolaemia could be assessed by TTE as well.
• Additionally, bedside compression ultrasound (CUS) can be used as a further radiation-free diagnostic approach to detect or
exclude proximal DVT. If PE is (in)directly confirmed.
• in all PE patients with haemodynamic instability a rescue thrombolytic treatment is recommended, if no absolute
contraindications for systemic thrombolysis are present, If these do exist, alternative treatment strategies such as
(percutaneous) thrombectomy should be considered.
DIAGNOSIS
Konstantinides, Stavros V., et al. "2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS) The Task Force for the diagnosis
and management of acute pulmonary embolism of the European Society of Cardiology (ESC)." European heart journal 41.4 (2020): 543-603.

6. DIAGNOSIS
Acute Pulmonary
Embolism
Stable Hemodynamic
Hobohm, Lukas, et al. "Pulmonary embolism and pregnancy–challenges in diagnostic and therapeutic decisions in high-risk patients." Frontiers in Cardiovascular Medicine (2022): 423.
Acute Pulmonary Embolism in Pregnancy

7. Acute Pulmonary Embolism in Pregnancy
• If there is a high or intermediate pretest probability, empirical heparin anticoagulation should be administered before diagnostic
imaging is initiated.
• If there are signs/symptoms of DVT, CUS should be performed. If CUS identifies DVT, the diagnosis of PE is—per definition—
confirmed indirectly. If no proximal DVT is present or the CUS is inconclusive, chest Xray followed (in the absence of parenchymal
pulmonary changes) by ventilation/perfusion scintigraphy (V/Q scan), or computed tomography pulmonary angiography (CTPA),
should be considered to rule out suspected PE.
• A multicentre prospective diagnostic management study validated the combination of pre-test clinical probability assessment
based on the Geneva score, highsensitivity D-dimer testing, CUS and CTPA in a diagnostic strategy for pregnant women with
suspected PE. Therefore, this diagnostic algorithm is able to safely rule out PE in pregnancy.
• The current ESC guidelines recommend to perform an X-ray in pregnant women with suspected PE. If the X-ray is normal, V/Q scan
should be performed, due to the fact, that V/Q scan is associated with low fetal and maternal radiation exposure. If the X-ray is
abnormal, showing, for example, pulmonary infiltrates, then CTPA should be performed directly.
DIAGNOSIS
ACUTE PULMONARY EMBOLISM WITH STABLE HEMODYNAMIC
Huisman, Menno V., et al. "2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS)." European Heart Journal 41 (2020): 543À603.

8. DISCUSSION
“ACUTE PULMONARY EMBOLISM IN COVID-19 “
Case Report

9. Acute Pulmonary Embolism in COVID-19
• At least two main phenotypes of COVID-19 patients with thrombotic lung injury can be identifed: patients afected by
“ordinary” VTE and patients showing pulmonary microthrombosis (PMT).
• Since DVT or other sources of VTE were not consistently found in COVID19 patients with PE, PMT could be the result of
local hypercoagulability rather than secondary to embolization from the lower limbs
• Formation of thrombi in the microvasculature may be a part of the physiological efort to limit the viral load.
• Indeed, viral invasion induces an intense infammation of the lungs which in turn triggers a local activation of hemostasis
driven by the interaction between platelets and endothelium.
• It has been speculated that a possible cornerstone of microthrombi generation during COVID-19 is related to endothelial
cells’ dysfunction
Sakr, Yasser, et al. "Pulmonary embolism in patients with coronavirus disease-2019 (COVID-19) pneumonia: a narrative review." Annals of intensive care 10.1 (2020): 1-13.

10. Acute Pulmonary Embolism in COVID-19
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Y Sakr, Yasser, et al. "Pulmonary embolism in patients with coronavirus disease-2019 (COVID-19) pneumonia: a narrative review." Annals of intensive care 10.1 (2020): 1-13.

11. DISCUSSION
“ACUTE PULMONARY EMBOLISM IN
PREGNANCY WITH COVID-19“
Case Report

12. Acute Pulmonary Embolism in Women With COVID-19
Case Report
Goudarzi, Sogand, et al. "Pulmonary embolism in pregnancy with COVID‐19 infection: A case report." Clinical Case Reports 9.4 (2021): 1882-1886.
The Case report a 22-year-old pregnant woman
with coronavirus admitted due to the pulmonary
emboli. This case highlights the importance of
considering a new category for COVID-19
pregnant patients with venous and arterial
thromboembolic disorders.

13. Acute Pulmonary Embolism in Women With COVID-19
• Higher D-dimer levels (more than 0.5 µg/mL) are considered as an indirect indicator for increased thrombin production and are
associated with an increased risk of death. Anticoagulant therapy with low molecular weight heparin (LMWH) shows promising
results in the prognosis of severe COVID-19 patients with higher levels of D-dimer by limiting the extent of coagulopathy.
• Treatment by heparin can also reduce the inflammatory biomarkers leading to a decline in the severity of COVID-19 infection.
According to a study by Betoule et al, preventive anticoagulant treatments should be considered in COVID-19 nonpregnant
patients with D-dimer ≥ 3 μg/ml (11 mdf).
• Dashraath et al determined that pregnant women suspected of the severe form of COVID-19 infection during the third trimester
are at a higher risk of thromboembolic disorders. Therefore, they suggested that these pregnant women be given the
prophylactic weight-adjusted dose of heparin during hospitalization, and continued until delivery and six weeks postpartum
DISCUSSION
Goudarzi, Sogand, et al. "Pulmonary embolism in pregnancy with COVID‐19 infection: A case report." Clinical Case Reports 9.4 (2021): 1882-1886.

14. DISCUSSION
“MANAGEMENT ACUTE PULMONARY
EMBOLISM IN PREGNANCY“
Case Report

15. Management Acute Pulmonary Embolism in Pregnancy
• LMWH is the treatment of choice for PE during pregnancy. In contrast to VKAs and NOACs, LMWH does not cross the placenta,
and consequently does not confer a risk of foetal haemorrhage or teratogenicity.
• Fondaparinux may be considered if there is an allergy or adverse response to LMWH, although solid data are lacking and minor
transplacental passage has been demonstrated.
• The management of labour and delivery requires particular attention. In women receiving therapeutic LMWH, strong
consideration should be given to planned delivery in collaboration with the multidisciplinary team to avoid the risk of
spontaneous labour while fully anticoagulated. The incidence of spinal haematoma after regional anaesthesia is unknown in
pregnant women under anticoagulation treatment. If regional analgesia is considered for a woman receiving therapeutic LMWH,
>_24 h should have elapsed since the last LMWH dose before insertion of a spinal or epidural needle (assuming normal renal
function and including risk assessment at extremes of body weight)
Huisman, Menno V., et al. "2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS)." European Heart Journal 41 (2020): 543À603.

16. Management Acute Pulmonary Embolism in Pregnancy
• In high-risk situations, it is recommended that LMWH be converted to UFH ≥ 36 hours before delivery. The UFH infusion
should be discontinued 4 - 6 hours before delivery and the activated aPTT should be normal (ie not prolonged) prior to
administration of regional anesthesia.
• If the haemodynamic status aggravates, thrombolytic agents may be necessary to administer. Immediate thrombolytic treatment is
recommended unless absolute contraindications for systemic thrombolysis are present.
• Besides thrombolysis, other treatment options of high-risk PE as surgical or percutaneous thrombectomy in should be taken into
account. If necessary also extracorporeal membrane oxygenation (ECMO) can be considered for depressurize the right ventricle and
pulmonary circulation.
• In the case of absolute contraindications, alternative treatment strategies such as surgical embolectomy or percutaneous low-dose
thrombolysis (CDT) or thrombectomy should be considered.
• An additional treatment option for pregnant women with absolute contraindications for anticoagulation could be the placement of an
inferior vena cava (IVC) filter.
• Data are limited on the optimal timing of post-partum reinitiation of LMWH. Timing will depend upon the mode of delivery and an
assessment of the thrombotic vs. bleeding risk by a multidisciplinary team. LMWH should not be given for≥ 4 h after removal of the
epidural catheter, the decision on timing and dose should consider whether the epidural insertion was traumatic, and take into
account the risk profile of the woman.
• Anticoagulant treatment should be administered for >_6 weeks after delivery and with a minimum overall treatment duration of 3
months. LMWH and warfarin can be given to breastfeeding mothers, the use of NOACs is not recommended.
Hobohm, Lukas, et al. "Pulmonary embolism and pregnancy–challenges in diagnostic and therapeutic decisions in high-risk patients." Frontiers in Cardiovascular Medicine (2022): 423.

17. CONCLUSION
“ACUTE PULMONARY EMBOLISM IN PREGNANCY WITH
COVID-19 “
A 34 year old woman, Diagnosis G5P2A2 Gravid 38 weeks 5 days with Bilateral Pneumonia and Cardiomegaly.
Enforcement of the diagnosis in this patient is established through anamnesis, physical examination and supporting
examinations in the form of laboratory tests, X-Ray Thorax, ECG and echocardiography. Patient diagnosed, Suspected Acute
Pulmonary Embolism with high risk stratification and COVID 19 with Coagulopathy.
Management in this patient is in the form of anticoagulation with regard to contraindications in the patient, and is
planned for the implementation of SC CITO. Prior to the SC procedure, the patient experienced agitation and cardiac arrest, the
patient was declared dead.
The results of this case report are expected to help doctors to prepare themselves well to treat patients with the
same case with the aim of saving the patient's life.