Peripartum Pulmonary Embolism: From Diagnoses to Management

Pulmonary embolism (PE) is a life-threatening clinical condition during pregnancy and peripartum. There is a significant increase in the risk of PE postpartum. There are various risk factors for PE in pregnant patients. The most absolute risk factor is hereditary thrombophilia. The pathophysiology of PE is venodilatation, increase in venous volume, and venous stasis along with endothelial damage or injury during pregnancy and postpartum period due to hormonal and hematological changes. For the probability scoring for PE, the clinical criteria are not well-defined in pregnancy. Echocardiogram may show right-sided heart changes. The diagnostic tool most frequently used is CTPA (computed tomographic pulmonary angiography) as it is easily available and may give an alternative diagnosis. If there is no PE, lower limb deep venous thrombosis (DVT) can be easily diagnosed with ultrasound Doppler. Pending diagnosis of DVT/PE, the anticoagulation should be started early, once more, it is critical to prevent missing or delayed diagnoses. The low molecular weight heparin during pregnancy and unfractionated heparin in the postpartum period are the anticoagulant agents of choice, as they are reversible and have no fetal effects of low molecular weight heparin and are safe. Warfarin is not used due to its teratogenic effect. The new oral anticoagulants are not frequently used as safety is yet to be proved. If the patient is in shock with PE, thrombolysis, thrombectomy, or ECMO therapy can be done. PE can be prevented up to some extent with LMWH during pregnancy and thrombophilia patients and the use of elastic stockings and early mobility in low-risk patients.