The woman who has very recently sufered a pulmonary embolism and who must undergo cesarean delivery presents a particularly serious problem. Reversal of anticoagulation may be followed by another embolus, and surgery while ully anticoagulated frequently results in life-threatening hemorrhage or troublesome hematomas. In these cases, placement of a vena caval ilter should be considered before surgery (Marik, 2008). Moreover, in the very infrequent circumstances in which heparin therapy fails to prevent recurrent pulmonary embolism from the pelvis or legs, or when embolism develops from these sites despite heparin treatment, a vena caval ilter may also be indicated. Such filters can also be used following massive emboli in patients who are not candidates for thrombolysis (Deshpande, 2002).
he device is inserted through either the jugular or femoral vein and can be inserted during labor Jamjute, 2006). Routine filter placement has no added advantage to heparin given alone (Decousus, 1998). Retrievable ilters may be used as short-term protection and then removed 1 to 2 weeks later (Liu, 2012). From their systematic review, Harris and associates (2016) found that complication rates in pregnant women with vena caval filters are comparable to those in nonpregnant patients.
Compared with heparin, thrombolytic agents provide more rapid lysis of pulmonary clots and improvement of pulmonary hypertension (Tapson, 2008). Konstantinides and coworkers (2002) studied 256 nonpregnant patients receiving heparin for an acute submassive pulmonary embolism. hey also were randomly assigned to a placebo or the recombinant tissue plasminogen activator alteplase. hose given the placebo had a threefold greater risk of death or treatment escalation compared with those given alteplase. Agnelli and associates (2002) per formed a metaanalysis of trials involving 461 nonpregnant patients. They reported that the risk of recurrence or death and heparin compared with those given heparin alone-1 0 versus 17 percent. Importantly, however, there were ive-2 percent-fatal bleeding episodes in the thrombolysis group and none in the heparin-only group.
In their review, Leonhardt and colleagues (2006) identiied 28 reports of tissue plasminogen activator use during pregnancy. T en cases were for thromboembolism. Complication rates were similar to those in nonpregnant patients, and the authors concluded that such therapy should not be withheld during pregnancy if indicated. However, Akazawa and Nishida (2017) reviewed 13 cases of systemic thrombolytic therapy administered during the irst 48 hours after delivery. Blood transfusion was required in five of the eight cesarean deliveries, including three cases of hysterectomy and two cases of hematoma removal.
Given the eicacy of thrombolysis and filters, surgical embolectomy is uncommonly indicated. Published experience with emergency embolectomy during pregnancy is limited to case reports (Colombier, 2015; Saeed, 2014). From their review, Ahearn and associates (2002) found that although the operative risk to the mother is reasonable, the stillbirth rate is 20 to 40 percent.