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High-risk, life-threatening PE during pregnancy is a rare, but potentially devastating, event. A recent systematic review included 127 cases of severe PE during pregnancy (and until 6 weeks post-partum) treated with thrombolysis, thrombectomy, and/or ECMO.421 Both high- and intermediate-risk PE cases were included, and 23% of women experienced cardiac arrest. Reported survival rates were 94 and 86% following thrombolysis and surgical thrombectomy, respectively; however, these favourable rates may reflect reporting bias. Following thrombolysis, major bleeding occurred in 18 and 58% of cases during pregnancy and in the post-partum period, respectively.421 Finally, foetal deaths occurred in 12 and 20% of the cases following thrombolysis and thrombectomy, respectively.421 Thrombolytic treatment should not be used peri-partum, except in the setting of life-threatening PE. Typically, UFH is used in the acute treatment of high-risk PE. Although the indications for vena cava filters are similar to those for non-pregnant patients (discussed in section 6), there is limited experience with their use in pregnancy and the risk associated with the procedure may be increased. Suggestions for the anticoagulation management of PE in specific clinical situations (also) related to pregnancy, for which conclusive evidence is lacking, are presented in Supplementary Data Table 9.

9.3.1 Role of a multidisciplinary pregnancy heart team A team of multidisciplinary colleagues should collaborate in the planning of ante-, peri-, and post-partum care pathways for women with cardiovascular diseases, including PE. As many members as possible of this team should have expertise in the management of PE during pregnancy and the post-partum period. Jointly agreed, written care pathways should be available (if timelines permit) for effective communication (an example is shown in Figure 7).

9.4 Amniotic fluid embolism

Amniotic fluid embolism (AFE) is a rare condition that occurs during pregnancy or shortly after delivery. It remains one of the leading causes of direct maternal death (i.e. death resulting from the pregnancy rather than from pre-existing conditions) in high-income countries.422 Diagnosis of AFE is challenging, being primarily a clinical diagnosis of exclusion. Awareness of AFE, prompt diagnosis, and aggressive life support are of critical importance. AFE is characterized by unexplained sudden cardiovascular or respiratory deterioration, often accompanied by disseminated intravascular coagulation,422 and occurring during pregnancy or after delivery.423,424 The reported incidence is approximately 27 per 100 000 maternities, with a mortality rate of 0.56 deaths per 100 000 deliveries.422,425,426 Reported case fatality rates vary, reflecting the challenges in making the diagnosis and the rarity of AFE. In a retrospective Californian study including more than 3.5 million deliveries, a case fatality rate of 13% was reported, as in other US and Canadian studies.425 Similarly, a case fatality rate of 19% was reported in a recent prospective UK population-based study with validated case criteria.422 Recent literature have suggested that risk factors for AFE may include pre-existing cardiac, cerebrovascular, and renal disorders, placenta previa, polyhydramnios, stillbirth, chorioamnionitis, hypertensive disorders, instrumental delivery, and caesarean section.422,425 Management of AFE is supportive, and based on high-quality emergency care following the recognition and diagnosis of the condition, with prompt treatment of bleeding and coagulopathy.423 Awareness of AFE should be integral to the education of involved physicians and to emergency algorithms.

9.5 Recommendations for pulmonary embolism in pregnancy

Recommendations Classa Levelb

Diagnosis Formal diagnostic assessment with validated methods is recommended if PE is suspected during pregnancy or in the post-partum period.388,391 I B D-dimer measurement and clinical prediction rules should be considered to rule out PE during pregnancy or the post-partum period.388,391 IIa B In a pregnant patient with suspected PE (particularly if she has symptoms of DVT), venous CUS should be considered to avoid unnecessary irradiation.388 IIa B Perfusion scintigraphy or CTPA (with a low-radiation dose protocol) should be considered to rule out suspected PE in pregnant women; CTPA should be considered as the first-line option if the chest X-ray is abnormal.385,386 IIa C Treatment A therapeutic, fixed dose of LMWH based on early pregnancy body weight is the recommended therapy for PE in the majority of pregnant women without haemodynamic instability.408,410 I B Thrombolysis or surgical embolectomy should be considered for pregnant women with highrisk PE.421 IIa C Insertion of a spinal or epidural needle is not recommended, unless >_24 h have passed since the last therapeutic dose of LMWH. III C Administration of LMWH is not recommended within 4 h of removal of an epidural catheter. III C NOACs are not recommended during pregnancy or lactation. III C Amniotic fluid embolism Amniotic fluid embolism should be considered in a pregnant or post-partum woman with otherwise unexplained cardiac arrest, sustained hypotension, or respiratory deterioration, especially if accompanied by disseminated intravascular coagulation.422,425,426 IIa C

CTPA = computed tomography pulmonary angiography; CUS = compression ultrasonography; DVT = deep vein thrombosis; LMWH = low-molecular weight heparin; NOACs = non-vitamin K antagonist oral anticoagulants; PE = pulmonary embolism. aClass of recommendation. bLevel of evidence. Downloaded from academic.oup.com/eurheartj/article/41/4/543/5556136 by guest on 07 October 2026