Thrombolysis in pregnancy: a literature review

Changes in the coagulation system during pregnancy and puerperium produce a physiological hypercoagulable state. These changes are thought to be the cause of the higher rates of deep vein thrombosis (DVT), pulmonary embolism (PE), stroke, and mechanical prosthetic valve thrombosis (PVT) during pregnancy. Thrombolysis can be a treatment option in this case. However, there are no available data from randomized controlled trials in pregnant patients and information about the security of thrombolytics in pregnancy is missing.

The aim of this review is to summarize the available data regarding the use of thrombolytic agents in pregnancy, describing maternal and fetal outcomes.

A systematic review was performed, searching the electronic database MEDLINE for relevant studies published up to April 2017. The search included MeSH terms "thrombolytic therapy" OR "fibrinolysis" OR "streptokinase" OR "tissue plasminogen activator" AND "pregnancy". All publications that reported the use of a thrombolytic agent for DVT, PE, stroke or PVT in pregnancy were included in the review. Data on the type and total dose of the thrombolytic agent, gestational week, outcome of mothers and children, preterm delivery and bleeding complications were described.

Sixty-five articles have been published describing outcomes in 141 pregnant women with serious thrombotic events. There have been no randomized trials involving the use of thrombolytics in pregnancy. Only one prospective study was found. Four maternal deaths (2.8%), 12 major bleeding episodes (8.5%), 13 mild/moderate bleeding episodes (9.2%), two fetal death (1.4%), one child death (0.7%), nine miscarriages (6.4%), and 14 preterm delivery (9.9%) were described.

The risk of using thrombolytics in pregnancy seems reasonable taking into account the risk of death in a life-threatening event, with the majority of cases presented in this article resulting in encouraging outcomes. The complication rate of thrombolytic treatment does not seem higher in pregnant women than in the nonpregnant. Poor fetal outcome occurred in mothers with poor prognosis. Specific consensus recommendations are needed in the use of thrombolytics in pregnancy.