Fatal pulmonary embolism: a retrospective clinical study conducted in women aged between 18 to 45 years and review of the literature

Abstract

Aim: Pulmonary embolism (PE) and deep venous thrombosis (DVT) represent components of the same pathological entity, the venous thromboembolism (VTE). Recent epidemiological studies suggest that in certain conditions women of reproductive age may be prone to develop fatal PE. This retrospective study evaluates the risk factors of fatal PE in women of reproductive age between 18 to 45 years, in the light of data from scientific literature.Methods and Results: The files from sixteen consecutive fatal cases of PE recorded in women over 10 years (1990-1999) were retrieved from the archive of the Forensic Pathology Section at the Faculty of Medicine in Auckland, New Zealand. The demographic data and the pathologist?s histological report including the final diagnosis were closely correlated. Obesity was the only pathological finding in four cases (25%) although it was also found associated with other risk factors in another five cases (31%). Cardiovascular disease and deep venous thrombosis were identified as major risk factors of PE in three cases each (18%). Malignancy, oral contraceptive administration and postpartum thromboembolism were reported in three separate cases. In two patients, it was not possible to identify the cause of fatal pulmonary thromboembolism. Discussion and Conclusions: Our observations appear to indicate that obesity is the most important risk factor for fatal pulmonary thromboembolism in women of child-bearing age. Numerous studies have shown that obesity may play this role by bringing about and perpetuating an inflammatory state which then leads to thrombosis through a variety of mechanisms, including the prothrombotic action of some adipose tissue hormones and abnormal fibrinolysis and coagulation in the background of endothelial dysfunction. Obesity may also be associated with various other risk factors or pathological conditions in which thrombosis occurs via several other recognized pathways. Due to the prime etiological significance of obesity, it is reasonable to refer to this condition as "(fatal) obesity-related pulmonary embolism" (ORPE). It would thus follow that if pulmonary embolism appears not to be associated with obesity, these cases should be referred to as "(fatal) non-obesity related pulmonary embolism" (NORPE). In case of over-weight or obese patients, the prophylaxis against fatal PE should start early and should always include drug therapy and weight loss programs which would be designed to diminish or lessen the prothrombotic factors leading to VTE.