A Rare and Complex Intersection: Pulmonary Embolism With Right-Sided Empyema in Early Pregnancy – A Case Report Highlighting Diagnostic and Ethical Challenges

Acute dyspnoea in pregnancy is a challenging diagnosis since physiological alterations can mask severe cardiopulmonary disease. A 26-year-old gravida 2 para 1 at 11 weeks and 3 days gestation came with a history of acute onset of breathlessness for four hours. Physical examination: tachypnoea, hypoxemia, sinus tachycardia, and reduced air entry on the right. Bedside point-of-care ultrasound revealed right atrial and ventricular dilatation, no RV dysfunction (TAPSE-1.6cm), and right-sided pleural effusion. After the primary survey and adjuncts, the YEARS clinical decision rule was used. A CT pulmonary angiography (CTPA) was indicated by the elevated D-dimer and clinical presentation, which indeed confirmed acute pulmonary embolism. The patient was started on intravenous unfractionated heparin 5000 IU. CTPA revealed a loculated right-sided empyema as well. Empiric broad-spectrum antibiotics were started, and a pigtail catheter was placed for drainage of empyema. Pleural fluid analysis indicated a tuberculous cause- anti-tubercular therapy was started. Due to the requirement of repeated radiation imaging and invasive interventions, a multidisciplinary clinic counselled and went ahead with medical termination of pregnancy. The patient subsequently improved considerably after the procedure and could be discharged on continued anticoagulation and anti-tubercular treatment. This case ascertains the importance of timely bedside imaging, early anticoagulation, intense source control of empyema, and well-coordinated multidisciplinary care. It also demonstrates the moral dilemma of giving precedence to maternal survival when foetal safety is involved. The combination of pulmonary embolism and empyema during early pregnancy is very rare, and this report serves as a useful guide for such complex presentations.