Total hysterectomy with preoperative IVC filter and uterine artery embolization successfully managed acute pulmonary embolism in a 39-year-old pregnant patient with a compressive uterine fibroid.
Case Report (n=1)
Multidisciplinary management including total hysterectomy can safely address both reproductive choice and thrombotic risk in pregnant patients with acute PE and severe pelvic venous compression.
Abstract Introduction Pregnancy significantly increases the risk of venous thromboembolism (VTE), and venous compression from the gravid uterus and underlying pelvic structures further elevates risk. Uterine fibroids and May-Thurner-like pathology from iliac vein compression may compound venous stasis, complicating both anticoagulation and pregnancy management. We present a case of acute pulmonary embolism (PE) in early pregnancy in which the patient’s desire for pregnancy termination intersected with management of thrombotic risk and uterine mass effect. Case Description A 39-year-old G3P2 woman at 13 weeks’ gestation presented with progressive dyspnea and left leg swelling. Computed tomographic (CT) angiogram of the chest demonstrated bilateral main pulmonary artery emboli extending to segmental branches as well as enlarged pulmonary arteries, suggestive of pulmonary arterial hypertension. Magnetic resonance imaging (MRI) of the pelvis confirmed a viable intrauterine pregnancy and a pedunculated fibroid markedly displacing the uterus, consistent with mechanical venous compression physiology. Bilateral lower extremity deep vein thromboses (DVT) were also visualized. She reported a history of peripartum DVT/PE after a prior cesarean section, treated with rivaroxaban. She was started on a full intensity intravenous unfractionated heparin infusion and classified as intermediate-low risk PE, with troponin 6ng/L and no evidence of right ventricular dysfunction on transthoracic echocardiogram. The patient requested pregnancy termination. Due to uterine displacement from the fibroid and concern for venous compression, a multidisciplinary consensus recommended total hysterectomy over dilation and evacuation to relieve venous compression and terminate pregnancy. The patient returned two weeks after discharge for planned surgery. An inferior vena cava (IVC) filter and uterine artery embolization were performed preoperatively to mitigate embolic and hemorrhagic risk. She subsequently underwent total hysterectomy with bilateral salpingectomy without complication. Anticoagulation was transitioned postoperatively from enoxaparin to apixaban, and she was discharged home in stable condition. Discussion This case underscores the interplay between pregnancy-associated thrombosis, venous compression, and reproductive decision-making. The presence of a large fibroid likely exacerbated lower extremity venous stasis reminiscent of May-Thurner syndrome, an underrecognized condition in both pregnant and non-pregnant patients. The need to safely manage acute PE while respecting the patient’s preference for pregnancy termination required delaying definitive surgery to optimize anticoagulation and reduce perioperative risk. Total hysterectomy offered dual benefits: termination of pregnancy and removal of a compressive pelvic mass contributing to thrombosis risk. This case highlights the importance of multidisciplinary planning in managing VTE during pregnancy. This abstract is funded by: None
Hashem et al. (Fri,) conducted a case report in Pulmonary embolism in pregnancy with May-Thurner-like pathology (n=1). Total hysterectomy, IVC filter, uterine artery embolization, and anticoagulation was evaluated. Total hysterectomy with preoperative IVC filter and uterine artery embolization successfully managed acute pulmonary embolism in a 39-year-old pregnant patient with a compressive uterine fibroid.
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