Catheter-directed thrombolysis in a case of postpartum acute intermediate-high risk pulmonary embolism

Introduction Venous thromboembolism is the third most frequent acute cardiovascular pathology in the general population. Several risk factors have been described, including pregnancy and postpartum status. Case Presentation We present the case of a puerperal woman (after the fifth natural childbirth), who was diagnosed with grade II gestational hypertension four weeks before giving birth, when bed rest was recommended by her physician. The patient was admitted for dyspnea and extreme fatigue during minimal exertion, with symptoms starting immediately after birth and suddenly aggravated three days prior to presentation. She had a heart rate of 115 bpm and a blood pressure of 140/90 mmHg. The resting electrocardiogram depicted sinus tachycardia, signs of right ventricular strain and S1Q3T3 pattern. The echocardiography revealed a severely enlarged right ventricle with poor systolic function, as well as signs of right ventricle pressure overload and a high probability of pulmonary hypertension. NT-proBNP and high-sensitive troponin were mildly elevated. The computed tomographic pulmonary angiography confirmed the diagnosis of intermediate-high risk pulmonary embolism. Under treatment with unfractionated heparin, the patient’s condition did not improve. After a thorough, team-based evaluation of the risk/benefit ratio, standard catheter-directed thrombolysis was performed, with good immediate and long-term outcomes. Conclusions Catheter directed thrombolysis could be an effective treatment of postpartum pulmonary thromboembolism, with a reasonable hemorrhagic risk. Postpartum and pregnant women are usually excluded from clinical trials, thus disproportionately limiting their access to novel therapies with high potential benefits. In such patients, an informed, individualized, team-based decision should be made.