Treatment options for severe pulmonary embolism during pregnancy and the postpartum period: a systematic review.

Essentials The evidence on how to manage life-threatening pregnancy-related pulmonary embolism (PE) is scarce. We systematically reviewed all available cases of (sub)massive PE until December 2016. Thrombolysis in such severe PE was associated with a high maternal survival (94%). The major bleeding risk was much greater in the postpartum (58%) than antepartum period (18%). SUMMARY: Background Massive pulmonary embolism (PE) during pregnancy or the postpartum period is a rare but dramatic event. Our aim was to systematically review the evidence to guide its management. Methods We searched Pubmed, Embase, conference proceedings and the RIETE registry for published cases of severe (submassive/massive) PE treated with thrombolysis, percutaneous or surgical thrombectomy and/or extracorporeal membrane oxygenation (ECMO), occurring during pregnancy or within 6 weeks of delivery. Main outcomes were maternal survival and major bleeding, premature delivery, and fetal survival and bleeding. Results We found 127 cases of severe PE (at least 83% massive; 23% with cardiac arrest) treated with at least one modality. Among 83 women with thrombolysis, survival was 94% (95% CI, 86-98). The risk of major bleeding was 17.5% during pregnancy and 58.3% in the postpartum period, mainly because of severe postpartum hemorrhages. Fetal deaths possibly related to PE or its treatment occurred in 12.0% of cases treated during pregnancy. Among 36 women with surgical thrombectomy, maternal survival and risk of major bleeding were 86.1% (95% CI, 71-95) and 20.0%, with fetal deaths possibly related to surgery in 20.0%. About half of severe postpartum PEs occurred within 24 h of delivery. Conclusions Published cases of thrombolysis for massive PE during pregnancy and the postpartum period suggest a high maternal and fetal survival (94% and 88%). In the postpartum period, given the high risk of major bleeding with thrombolysis, other therapeutic options (catheter [or surgical] thrombectomy, ECMO) may be considered if available.

OS108. Preeclamptic women display salt sensitivity and cardiovascular damage before their menopause.

INTRODUCTION: Salt sensitivity is an important cardiovascular risk factor. It has been shown that preeclamptic (PEC) women may not be totally cured after the delivery and keep a higher cardiovascular risk than nonPEC women. OBJECTIVES: We aimed to study the salt sensitivity of the blood pressure in women with a history of severe preeclamspia and women with no history of hypertensive complications.The design was a case control study with intervention, including 42 women recruited 5 to 17 years following delivery. METHODS: 21 women having suffered from a severe preeclampsia before 34 weeks of pregnancy and 19 age, race matched controls women,were randomized to follow for one week a low salt (LS) diet and a high salt (HS) diet (adding 6g NACL/d to usual diet). On day seven of each dietary period, 24h ambulatory blood pressure was recorded, and 24h urine collected in order to measure sodium excretion.Salt sensitivity was assigned if the mean 24h blood pressure increased by ⩾ 3mmHg on a high- compared with a low-salt diet. RESULTS: Preeclamptic women were aged 39.1(24-49) and controls 40.1(29-49), p=NS.Two of the PEC women already suffered from a cardiovascular event (2coronary events). The PEC women showed a significant increase of the BP and standard deviation (SD) of the BP compared to the controls.10 (47.6%) preeclamptic women showed salt sensitivity (odd ratio 5.4, 95% CI 0.972-30.601;P=0.042).Recurrent preeclampsia was associated with a significantly high risk to salt sensitivity status (OR 5; 95% confidence interval 1.1-31.6). CONCLUSION: Severe PEC women display already salt sensitivity of the blood pressure before their menopause and increased variability of the BP. Recurrent preeclampsia is a high risk factor for salt sensitivity and could allow to target this high-risk group at an early stage for preventive measures for cardiovascular disease.

[Is preeclampsia a new cardiovascular and end-stage renal diseases risk marker?]. / La prééclampsie: un nouvea facteur de risque de maladies cardiovasculaire et rénale?

Is preeclampsia a new cardiovascular and end-stage renal diseases risk marker? Preeclampsia is a major obstetrical problem leading to high maternal and perinatal morbidity and mortality worldwide. It is characterized by hypertension and proteinuria occurring after 20 weeks of gestation. Increasing evidence indicates that preeclampsia is not just a pregnancy disease that resolves at the time of delivery, but represent a risk marker of cardiovascular and end-stage renal diseases later in life. The underlying link between preeclampsia and cardiovascular disease is unclear. Women with early onset/severe preeclampsia, recurrent preeclampsia, or preeclampsia with onset as a multipara appear to be at highest risk of cardiovascular disease later in life, including during the premenopausal period.