Systemic Thrombolysis for Post-partum Pulmonary Embolism Complicated with Post-partum Haemorrhage

Pulmonary embolism (PE) is a potentially life-threatening complication, with the risk increasing four- to five-fold during pregnancy compared to non-pregnant women of similar age groups.¹ The incidence of venous thromboembolism (VTE) progressively rises throughout gestation and peaks in the postpartum period.² Thromboembolism remains the leading cause of direct maternal mortality in the UK as of 2022.³
We present a 26-year-old, previously healthy postpartum woman who developed acute respiratory distress and shock following an uncomplicated vaginal delivery. She exhibited rapid clinical deterioration with hypoxia, haemodynamic instability, and decreased responsiveness. Initial management included oxygen supplementation, intravenous fluid resuscitation, and vasopressor support. Arterial blood gas analysis demonstrated type 1 respiratory failure and metabolic acidosis. A bedside transthoracic echocardiogram revealed right atrial and right ventricular dilation with McConnell’s sign, raising strong suspicion for high-risk PE. Systemic thrombolysis with a reduced-dose alteplase regimen (50 mg over 2 hours) was commenced. However, after receiving 35 mg of alteplase, the patient developed significant vaginal bleeding that progressed to major postpartum haemorrhage with an estimated blood loss of 2 litres, requiring immediate cessation of thrombolysis and transfusion of blood and blood products.
Clinical improvement in oxygenation and haemodynamics was observed within six hours, consistent with effective thrombolysis. Subsequent CT pulmonary angiography confirmed a submassive right-sided PE.
This case highlights the importance of early recognition and urgent intervention of PE in postpartum patients and the complex balance  between life-saving thrombolysis and the elevated risk of postpartum haemorrhage.