Challenges in diagnosing and managing massive pulmonary thromboembolism during pregnancy following in vitro fertilization: A case report

Abstract Background : In vitro fertilization (IVF) significantly increases the risk of venous thromboembolism (VTE), particularly pulmonary thromboembolism (PTE), due to elevated estrogen levels during ovarian stimulation. Diagnosing PTE in pregnancy is challenging, making early detection and management essential to prevent severe maternal complications. Case presentation : This case report describes a 32-year-old woman, 9 weeks pregnant with twins, who presented with sudden dizziness and syncope. She had a history of four IVF procedures. Initial vital signs included tachycardia and normal blood pressure; however, she later developed severe hypotension and shock. Chest computed tomography confirmed the PTE, which was suggested on electrocardiogram and echocardiography. The performance of urgent thrombolysis with tissue plasminogen activator stabilized her condition but resulted in the loss of the twin gestational sacs. The patient was administered rivaroxaban and LMWH after being diagnosed with estrogen-associated PTE and mild anti-phospholipid antibody syndrome and successfully achieved a healthy pregnancy and delivery after further IVF attempts and prophylactic LMWH treatment. Conclusions : This case highlights the importance of rapid diagnosis and intervention for PTE during pregnancy and the need for tailored anticoagulation strategies to ensure maternal and fetal safety. Despite the tragic loss of the twin gestational sacs, appropriate anticoagulation therapy enabled the patient to achieve a successful pregnancy and healthy delivery in subsequent IVF attempts.