Advanced reperfusion therapies for acute pulmonary embolism in pregnancy and postpartum

Pulmonary embolism (PE) remains the leading preventable cause of maternal death in high-income countries. Data on the management of acute PE during pregnancy are limited because pregnant women are systematically excluded from interventional trials. We evaluated the use and outcomes of advanced reperfusion therapies in pregnancy-associated PE.

We performed a cross-sectional analysis of the US Nationwide Inpatient Sample from 2016 through 2020. Pregnancy- and puerperium-related hospitalizations were identified using ICD-10-CM codes. High-risk PE was defined by shock, mechanical ventilation, cardiac arrest, cardiopulmonary resuscitation, or vasopressor support. Advanced reperfusion therapies included systemic thrombolysis (ST), catheter-directed therapy (CDT), surgical embolectomy, and venoarterial extracorporeal membrane oxygenation (VA-ECMO).

Among 19,741,880 pregnancy- or puerperium-related hospitalizations, 12,715 (0.06%) were complicated by PE, corresponding to 6.7 (95% CI, 6.6-6.8) hospitalizations per 10,000 live births. The overall in-hospital mortality rate was 0.86% (0.058 [95% CI, 0.048-0.070] deaths per 10,000 live births). Mortality was 0.2% among patients without hemodynamic instability and 29.1% among those with high-risk PE. Advanced reperfusion therapies were used in 3.4% of all pregnancy-associated PE cases and in 32.7% of high-risk cases. In-hospital mortality was 9.8% after ST, 10.7% after CDT, and 50% after VA-ECMO. Major bleeding occurred in 15.7%, 10.7%, and 50%, respectively.

Pregnancy-associated PE is rare but associated with high mortality in high-risk presentations. Advanced reperfusion therapies are used infrequently, reflecting the limited evidence, highlighting the need for multidisciplinary managements, and further research and guidance.