Pregnancy-related pulmonary embolism: Clinical characteristics, management and outcomes in a South African academic hospital
DOI:
https://doi.org/10.7196/SAMJ.2026.v116i2.3722Keywords:
pregnancy, pulmonary embolism, South Africa, low molecular weight heparinAbstract
Background. Pulmonary embolism (PE) is a leading cause of death in pregnant and postpartum women.
Objective. To evaluate the clinical presentation, management and outcomes of pregnancy-related PE managed by a multidisciplinary team.
Methods. A retrospective review was conducted of pregnant and postpartum women diagnosed with PE between 2018 and 2024 at a tertiary hospital in Johannesburg, South Africa. Pretest probability scores (pregnancy-adapted YEARS and Geneva) were applied in a subgroup with D-dimers available.
Results. Seventy-seven women were included: 33 with antepartum and 44 with postpartum PE. The median (interquartile range) age was 29 (9) years, and most were of black African ethnicity. PE risk factors were present in 85% of antepartum and 96% of postpartum cases. Women with antepartum PE more frequently presented with chest pain, shortness of breath and palpitations (p<0.05). Pretest probability scores were assessed in a subgroup with D-dimers available. Based on the pregnancy-adapted YEARS and Geneva scores, imaging would have been required to rule out PE in 87.8% and 73.5% of cases, respectively. Computed tomography pulmonary angiography was the preferred diagnostic modality in 74.0%. Most women (97.4%) were treated as inpatients, and 57% required management in the intensive care and/or high care units. The median length of hospital stay was 14 (8) days. Low-molecular-weight heparin was the most frequently prescribed anticoagulant, with a median treatment duration of 3 (1) months. The live birth rate was 84.4%. One maternal death occurred due to sepsis, unrelated to venous thromboembolism. Antepartum/secondary postpartum major bleeding and primary postpartum major bleeding occurred in 6.5% and 3.9%, respectively.
Conclusion. Pregnancy-associated PE managed by a multidisciplinary team was associated with favourable maternal and fetal outcomes.
References
1. Felker A, Patel R, Kotnis R, Kenyon S, Knight M (eds) on behalf of MBRRACE-UK. Saving lives,
improving mothers’ care compiled report – lessons learned to inform maternity care from the UK
and Ireland confidential enquiries into maternal deaths and morbidity 2020 - 22. Oxford: National
Perinatal Epidemiology Unit, University of Oxford, 2024. https://www.npeu.ox.ac.uk/mbrrace-uk/
reports/maternal-reports/maternal-report-2020-2022 (accessed 16 February 2026).
2. Elendy IY, Fogerty A, Blanco-Molina A, et al. Clinical characteristics and outcomes of women presenting
with venous thromboembolism during pregnancy and postpartum period: Findings from the RIETE
Registry. Thromb Haemost 2020;120(10):1454-1462. https://doi.org/10.1055/s-0040-1714211
3. Moodley J, Fawcus S, Pattinson R. 21 years of confidential enquiries into maternal deaths in South
Africa: Reflections on maternal death assessments. O&G For 2020;30(4):4-7. https://journals.co.za/
doi/abs/10.10520/ejc-medog-v30-n4-a2
4. Dangwang C, Temgoua V, Agbor AT, Tankeu AT, Noubiap JJ. Epidemiology of venous
thromboembolism in Africa: A systematic review. J Thromb Haemost 2017;15(9):1770-1781. https://
doi.org/10.1111/jth.13769
5. Barillari G, Londero AP, Brenner B, et al. Recurrence of venous thromboembolism in patients with
recent gestational deep vein thrombosis or pulmonary embolism: Findings from the RIETE Registry.
Eur J Intern Med 2016;32:53-59. https://doi.org/10.1016/j.ejim.2016.02.013
6. Pengo V, Lensing AW, Prins MH, et al. Incidence of chronic thromboembolic pulmonary hypertension
after pulmonary embolism. N Engl J Med 2004;22(350):2257-2264. https://doi.org/10.1056/
nejmoa032274
7. Croles FN, Nasserinejad K, Duvecot JJ, Kruip MJ, Meijer K, Leebeek FW. Pregnancy, thrombophilia,
and the risk of a first venous thrombosis: Systematic review and Bayesian meta-analysis. BMJ
2017;359:j4452. https://doi.org/10.1136/bmj.j4452
8. Schapkaitz E, de Jong PR, Jacobson BF, Buller HR. Recommendations for thromboprophylaxis in
obstetrics and gynaecology. S Afr J Obstetr Gynaecol 2018;24(1):24-28. https://doi.org/10.7196/
SAJOG.2018.v24i1.1312
9. Bates SM, Rajasekhar A, Middeldorp S, et al. American Society of Hematology 2018 guidelines for
management of venous thromboembolism: Venous thromboembolism in the context of pregnancy.
Blood Adv 2018;2(22):3317-3359. https://doi.org/10.1182/bloodadvances.2018024802
10. Nelson-Piercy C, MacCallum P, Mackillop L. Royal College of Obstetricians and Gynaecologists (2015)
Green-top Guideline No. 37a. Reducing the risk of thrombosis and embolism during pregnancy and
the puerperium. RCOG, 2015. https://www.rcog.org.uk/guidance/browse-all-guidance/green-topguidelines/
reducing-the-risk-of-thrombosis-and-embolism-during-pregnancy-and-the-puerperiumgreen-
top-guideline-no-37a/ (accessed 15 February 2026).
11. Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos A, Vandvik P. VTE, thrombophilia,
antithrombotic therapy, and pregnancy: Antithrombotic therapy and prevention of thrombosis, 9th ed:
American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141(2
Suppl):e691S-736S. https://doi.org/10.1378/chest.11-2300
12. Robert-Ebadi H, Elias A, Sanchez O, et al. Assessing the clinical probability of pulmonary embolism
during pregnancy: The Pregnancy Adapted Geneva (PAG) score. J Thromb Haemost 2021;19(12):3044-
3050. https://doi.org/10.1111/jth.15521
13. Van der Pol LM, Tromeur C, Bistervels IM, et al. Pregnancy-adapted YEARS algorithm for diagnosis
of suspected pulmonary embolism. N Engl J Med 2019;380(12):1139-1149. https://doi.org/10.1056/
nejmoa1813865
14. Langlois E, Cusson-Dufour C, Moumneh T, et al. Could the YEARS algorithm be used to exclude
pulmonary embolism during pregnancy? Data from the CT-PE-pregnancy study. J Thromb Haemost
2019;17(8):1329-1334. https://doi.org/10.1111/jth.14483
15. Tardy B, Chalayer E, Kamphuisen PW, et al. Definition of bleeding events in studies evaluating
prophylactic antithrombotic therapy in pregnant women: A systematic review and a proposal from the
ISTH SSC. J Thromb Haemost 2019;17(11):1979-1988. https://doi.org/10.1111/jth.14576
16. O’Shaughnessy F, Donnelly JC, Bennett K, Damkier P, Ainle FN, Cleary BJ. Prevalence of postpartum
venous thromboembolism risk factors in an Irish urban obstetric population. J Thromb Haemost
2019;17(11):1875-1885. https://doi.org/10.1111/jth.14568
17. Philipp CS, Faiz AS, Beckman MG, et al. Differences in thrombotic risk factors in black and white
women with adverse pregnancy outcome. Thromb Res 2014;133(1):108-111. https://doi.org/10.1016/j.
thromres.2013.10.035
18. Schapkaitz E, Libhaber E, Rhemtula H, et al. Pregnancy-related venous thromboembolism and HIV
infection. Int J Gynaecol Obstet 2021;155(1):110-118. https://doi.org/10.1002/ijgo.13596
19. Sliwa K, Libhaber E, Elliott C, et al. Spectrum of cardiac disease in maternity in a low-resource cohort
in South Africa. Heart 2014;100(24):1967-1974. https://doi.org/10.1136/heartjnl-2014-306199
20. Bellesini M, Robert-Ebadi H, Combescure C, Dedionigi C, le Gal G, Righini M. D-dimer to rule
out venous thromboembolism during pregnancy: A systematic review and meta-analysis. J Thromb
Haemost 2021;19(10):2454-2467. https://doi.org/10.1111/jth.15432
21. Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, et al. ESC Scientific Document Group. 2018
ESC guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J
2018;39(34):3165-3241. https://doi.org/10.1093/eurheartj/ehy340
22. Baglin T, Barrowcliffe TW, Cohen A, Greaves M. Guidelines on the use and monitoring of heparin. Br
J Haematol 2006;133(1):19-34. https://doi.org/10.1111/j.1365-2141.2005.05953.x
23. Jacobson B, Rambiritch V, Paek D, et al. Safety and efficacy of enoxaparin in pregnancy: A systematic
review and meta-analysis. Adv Ther 2020;37(1):27-40. https://doi.org/10.1007/s12325-019-01124-z
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