Journal of Pregnancy and Child Health
Open Access

Venous thromboembolism; pulmonary embolism; Pregnancy; Postpartum period; Thrombolytic therapy; Extracorporeal membrane oxygenation

Introduction

About 1 in 1000 to 3000 pregnant or postpartum women will get a pulmonary embolism. In its most severe form, high-risk PE, an acute widespread pulmonary artery blockage leads to hemodynamic instability and is associated with 15–50% in-hospital mortality in nonpregnant people [1]. Up to 7% of PEs during pregnancy may show this type of hemodynamic instability, and high-risk pregnancy-associated PE is to blame for 10% to 15% of all maternal deaths in North America and Europe [2]. In order to effectively treat the obstructive shock in high-risk PE patients, strong reperfusion treatments are needed, with systemic intravenous thrombolysis being the first option [3]. When reperfusion therapy is contraindicated, the patient is treated with transient hemodynamic replacement during the acute period in combination with therapeutic anticoagulation [4]. The management of high-risk PA-PE is even more challenging [5]. Due to dangers to the mother and the foetus, including maternal haemorrhage, prenatal toxicity, foetal loss, and premature birth [6].

Discussion

This clinically focused narrative review's objective is to give a thorough overview of the risk classification and targeted treatments for high-risk PA-PE [7]. We won't go into detail about how to diagnose PE during pregnancy or how to treat non-severe PAPE with anticoagulation because those topics have already been well-covered in previous reviews [8]. The modern management of acute PE must be tailored, and risk stratification is essential for this [9]. Due to the fact that circulatory failure is the main cause of death in severe PE, the article focuses on how the increased right ventricular afterload affects RV function [10]. The two-step risk stratification method is suggested by the European Society of Cardiology. First, high-risk PE is identified by the presence of cardiac arrest or hemodynamic instability, and reperfusion therapy is advised in these patients due to a significant risk of death from PE in the short term. The current ESC criteria include, apart from cardiac arrest, an obstructive shock accompanied by documented end-organ hypo perfusion, or a persisting hypotension defined as a systolic blood pressure <90 mm Hg or a drop of SBP ≥40 mm Hg without another cause. Second, in individuals with hemodynamic stability, the existence of RV Patients who may benefit from more extensive hemodynamic monitoring due to a higher risk of short-term clinical deterioration or from inpatient therapy in a medical ward are those with dilatation, raised troponin I or T, elevated B-type natriuretic peptide (BNP), or elevated N-terminal-proBNP. Does PA-PE fall under this risk classification? There are no research studies that we are aware of that address this issue. However, indirect data suggests that the clinical impression of hemodynamic instability used to diagnose high-risk PE should not be significantly modified by physiological changes brought on by pregnancy. To satisfy the metabolic demands of the mother and foetus, cardiac output increases by 50% during pregnancy.

Conclusion

Cardiac preload is increased through an increase in blood volume, while cardiac afterload is decreased through a significant decrease in systemic vascular resistance the heart rate increases due to resistance. Increased left ventricular mass and eccentric remodelling is also connected to this hyper dynamic condition. Compared to prepregnancy levels, a large recent prospective study has shown an overall rise of 20–25%, with an average increase of 9 bpm from the first to third trimesters (medians of 82 and 91, respectively). Therefore, from the 20th week of pregnancy, >10% of women have a heart rate greater than 100 bpm. Although hypotension is uncommon 3% of pregnancies have systolic blood pressure less than 95 mm Hg in the first and second trimesters and less than 102 mm Hg at term—it does often develop early in pregnancy through a 30% lowered SVR. The hemodynamic parameters quickly after delivery return to pre-pregnancy values. As a result, the 90 mm Hg threshold to diagnose a high-risk PE may be sufficient in the context of pregnancy. It is also utilised in the Maternal Early Warning criteria and the diagnostic criteria for sepsis in pregnant women.

Acknowledgement

None

Conflict of Interest

None

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