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Massive PE Thrombolysis Pregnancy — FRCA Final MCQ

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HardObstetric AnaesthesiaMassive PE Thrombolysis PregnancyFRCA Final

A 30-year-old woman (ASA I, 58 kg) at 35 weeks gestation develops sudden onset severe chest pain, breathlessness, and haemoptysis. She is tachycardic (HR 125), hypotensive (BP 85/50), and SpO2 88% on 15L O2. CTPA confirms massive bilateral pulmonary embolism. She is deteriorating rapidly. According to current guidelines, what is the most appropriate treatment?

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Correct answer: B — Systemic thrombolysis with alteplase

Massive PE with haemodynamic instability (hypotension, shock) is an indication for systemic thrombolysis, even in pregnancy. The risk of maternal death from untreated massive PE outweighs the bleeding risk of thrombolysis. Alteplase (tissue plasminogen activator) 50 mg IV over 1-2 hours is the standard dose (some protocols use 100 mg over 2 hours). Concurrent unfractionated heparin infusion should be started. In pregnancy, thrombolysis does not cross the placenta and is not directly fetotoxic. Alternative: surgical embolectomy or catheter-directed thrombolysis if available rapidly.

Reference: RCOG – 2015 – GTG 37b VTE in pregnancy; ESC – 2019 – PE guidelines; NICE – 2020 – NG158 VTE