MANAGEMENT OF CLOT IN TRANSIT IN A POST-PARTUM COVID-19 PATIENT

Background

39-year-old female, 34-week gravida with pregnancy complicated by gestational diabetes who presented with COVID-19.

Case

Patient presented to our hospital for 5 days of worsening dyspnea, cough, and fevers requiring oxygen on arrival. Given her respiratory decline, she underwent urgent cesarean delivery of a healthy male infant. Initial chest x-ray was consistent with severe COVID-19 pneumonia. Non-invasive methods of oxygenation were exhausted, and she was finally intubated several days later. Troponin was <0.02ng/mL, BNP was 71pg/mL, and D-Dimer increased from 601 to 13,000ng/mL. Transthoracic echocardiogram showed preserved cardiac function, but imaging was sub-optimal for the right ventricle (RV). On post-cesarean day 6, CT Pulmonary Angiogram (CTPA) showed bilateral segmental and subsegmental Pulmonary Embolism (PE) with a filling defect in the RV consistent with clot in transit (CIT). No RV strain was noted on echo or CTPA. Lower extremity venous duplex showed only acute calf thrombus. She was anticoagulated with enoxaparin at 1mg/kg, but her oxygen requirements worsened requiring 100% FiO2 on the ventilator.

Decision-making

Emergent multidisciplinary discussion was held by PE Response Team (PERT) regarding use of catheter directed lysis, systemic lysis, ECMO or surgical embolectomy. PERT team discussed extensively, and ultimately recommended 50mg alteplase be given systemically with family’s consent.

Conclusion

After alteplase was given, our patient’s oxygen requirements quickly improved to 45% FiO2 and her vitals remained normal. CT Head reported no hemorrhage, and repeat CTPA showed near-complete resolution of RV thrombus with mild increase in subsegmental thrombus. This case exemplifies the role of both emergent multidisciplinary decision-making in complex case scenarios, and systemic thrombolysis for the management of COVID-19 related CIT in patients who recently underwent cesarean delivery.