ABSTRACT

The pregnant woman has five times greater the risk of developing pulmonary thromboembolism with respect to non-pregnant, mainly due to the cardiovascular and coagulation changes characteristic of pregnancy, and the risk increases with the presence of other factors such as age, previous pulmonary embolism, systemic lupus erythematosus and multiparity, among others. The diagnostic process begins with clinical suspicion. Determination of D-dimer is useful because its negative predictive value. The helical computed tomography has a high sensitivity and specificity in the diagnosis of pulmonary thromboembolism, while pulmonary angiography remains the definitive diagnostic study. Treatment consists of anticoagulation as soon as the diagnosis is established, both unfractionated heparin and low molecular weight heparins are the drugs of choice over vitamin K antagonists, primarily because the first ones do not cross the placental barrier, and have fewer side effects due to their short half-life.

KEYWORDS

Pulmonary thromboembolism, pregnancy, puerperium, venous thromboembolic disease, deep vein thrombosis.

REFERENCES

1. Angulo-Vázquez J, Cortés Sanabria L, Torres-Gómez LG, Aguayo Alcázar G, Hernández Higareda S, Ávalos Nuño J. Analysis of maternal mortality during three periods at Hospital de Ginecología y Obstetricia del Centro Médico Nacional de Occidente. Ginecol Obstet Mex 2007;75:384-393.

2. Khan KS, Wojdyla D, Say L, Gülmezoqlu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet 2006;367:1066-1074.

3. Stone SE, Morris TA. Pulmonary embolism during and after pregnancy. Crit Care Med 2005;33:S294-S300.

4. Refuerzo JS, Hechtman JL, Redman ME, Whitty JE. Venous thromboembolism during pregnancy. Clinical suspicion warrants evaluation. J Reprod Med 2003; 48:767-770.

5. Angulo-Vázquez J, Ramírez-García A, Torres-Gómez LG, Vargas González A, Cortes Sanabria L. Pulmonary thromboembolism in obstetrics. Ginecol Obstet Mex 2004;72:400-406.

6. Weiss BM, Hess OM. Pulmonary vascular disease and pregnancy: current controversies, management strategies, and perspectives. Eur Heart J 2000;21:104-115.

7. Hunter S, Robson SC. Adaptation of the maternal heart in pregnancy. Br Heart J 1992;68:540-543.

8. Bourjeily G, Paidas M, Khalil H, Rosene-Montella K, Rodger M. Pulmonary embolism in pregnancy. Lancet 2010;375:500-512.

9. Chan WS, Ray JG, Murray S, Coady GE, Coates G, Ginsberg JS. Suspected pulmonary embolism in pregnancy: clinical presentation, results of lung scanning, and subsequent maternal and pediatric outcomes. Arch Intern Med 2002;162:1170-1175.

10. Santos-Martínez LE, Murillo C, Rodríguez A, et al. Medical reflections on a case of pulmonary thromboembolism in pregnancy. Arch Cardiol Mex 2010;80:255-260.

11. Bates SM, Greer IA, Middeldorp S, et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: antithrombotic therapy and prevention of thrombosis. 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141 (Suppl): e691S-e736S.

12. Wells PS, Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer. Ann Intern Med 2001;135:98-107.

13. Troffater KF, Howell ML, Greenberg CS, Hage ML. Use of the fibrin D- dimer in screening for coagulation abnormalities in preeclampsia. Obstet Gynecol 1989; 73:435-439.

14. Verduzco Rodríguez L, González Puebla E, Manffrini Madrid F, López Ariza B. D-dimer indifferent stages of pregnancy toxemia. A pilot study. Ginecol Obstet Mex 1998;66:77-80.

15. Bello RF, Patiño A, Dilena F, et al. Preeclampsia severa: dímero D como factor pronóstico en coagulopatía. Infor Med 2001;3:335-343.

16. To MS, Hunt BJ, Nelson-Piercy C. A negative D-dimer does not exclude venous thromboemboembolism (VTE) in pregnancy. J Obstet Gynaecol 2008;28:222-223.

17. Pruszczyk P, Bochowicz A, Torbicki A, et al. Cardiac troponin T monitoring identifies high-risk group of normotensive patients with acute pulmonary embolism. Chest 2003;123:1947-1952.

18. Horwich TB, Patel J, MacLellan R, Fonaraw GC. Cardiac troponin I is associated with impaired hemodynamics, progressive left ventricular dysfunction, and increased mortality rates in advanced heart failure. Circulation 2003;108:833-838.

19. Coma-Canela I, Gamallo C, Martínez Onsurbe PM, Lopez-Sendon J. Acute right ventricular infarction secundary to massive pulmonary embolism. Eur Hear J 1988;9:534-540.

20. Kucher N, Printzen G, Goldhaber SZ. Prognostic role of brain natriuretic peptide in acute pulmonary embolism. Circulation 2003;107:2545-2547.

21. McConnel MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT. Regional right ventricular dysfuntion detected by echocardiography in acute pulmonary embolism. Am J Cardiol 1996;78:469-473.

22. Goldhaber SZ. Echocardiography in the management of pulmonary embolism. Ann Intern Med 2002;136:691-700.

23. Cannon C, Goldhaber SZ. Cardiovascular risk stratification of pulmonary embolism. Am J Cardiol 1996;78:1149-1151.

24. Varsano S, Smorzik Y. Thrombolytic therapy for acute life-threatening pulmonary thromboembolism in a pregnant woman. Isr Med Assoc J 2008;10:740-741.

25. Leonhardt G, Gaul C, Nietsch HH, Buerke M, Schlewssner E. Thrombolytic therapy in pregnancy. J Thromb Thrombolysis 2006;21:271-276.

26. Sato T, Kobatake R, Yoshioka R, et al. Massive pulmonary thromboembolism in pregnancy rescued using transcatheter thrombectomy. Int Heart J 2007;48:269-276.

27. Stein PD, Fowler SE, Goodman LR; The PIOPED II investigators. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med 2006;354:2317-2327.

28. Matthews S. Short communication: Imaging pulmonary embolism in pregnancy: what is the most appropriate imaging protocol? Br J Radiol 2006;79:441-444.

29. Stone SE, Morris TA. Pulmonary embolism during and after pregnancy. Crit Care Med 2005;33:S294-S300.

30. Marik PE, Plante LA. Venous thromboembolic disease and pregnancy. N Engl J Med 2008;359:2025-2033.

31. Brown HL, Hiett AK. Deep vein thrombosis and pulmonary embolism in pregnancy: diagnosis, complications and management. Clin Obstet Gynecol 2010;53:345-359.

32. Mclintock C, Brighton T, Chunilal S, et al. Recommendations for the diagnosis and treatment of deep venous thrombosis and pulmonary embolism in pregnancy and the postpartum period. Aust N Z J Obstet Gynaecol 2012;52:14-22.

33. Barletta JF, Cooper B, Ohlinger MJ. Adverse drug events associated with disorders of coagulation. Crit Care Med 2010;38:S198-S218.

34. James AH. Thromboembolism in pregnancy: recurrence risks, prevention and management. Curr Opin Obstet Gynecol 2008;20:550-556.

35. Gupta S, Ettles DF, Robinson GJ, Lindow SW. Inferior vena cava filter use in pregnancy: preliminary experience. BJOG 2008;115:785-788.