HWN Suggests

Pulmonary Embolism Challenges in Diagnosis... Imaging, Pregnancy, Subsegmental PE

Subsegmental pulmonary embolism: To treat or not to treat? In the last 10 years, the incidence of diagnosed PE has doubled, despite no change in mortality, partly due to advances in CT technology and partly due to radiologists overcalling subsegmental PEs due to medico-legal concerns. With modern CTs, subsegmental PEs are more often diagnosed. Although there is some variability in practice, most emergency physicians end up treating subsegmental PEs. But should we?

read full article

Featured

 Thromboembolic Disease in Pregnancy and the Puerperium: Acute Management

In nonpregnant patients, the recommended therapeutic doses of LMWH vary according to the manufacturer (enoxaparin 1.5 mg/kg once daily; dalteparin 10 000–18000 units once daily depending on body weight; tinzaparin 175 units/kg once daily). During pregnancy, changes in volume of distribution and renal glomerular filtration rate result in alterations in the pharmacokinetics of LMWHs. Previous editions of this guideline (2001 and 2007) recommended a twice-daily dosage regimen for enoxaparin and dalteparin in the treatment of VTE in pregnancy (enoxaparin 1 mg/kg twice daily; dalteparin 100 units/kg twice daily). This recommendation was based on anti-Xa activity and a paucity of reports on safety and efficacy of once-daily dosing. Since then, a prospective multicentre observational study has found that 60% of practitioners use once-daily dosing of enoxaparin and dalteparin for treatment of VTE in pregnancy.

Articles of Interest

Pregnancy - Diagnosis of DVT & PE

The presentation of DVT in pregnancy differs from that in non-pregnant patients. The left leg is affected in >80% of cases and pregnant patients are much more likely to present with isolated iliac and/or femoral vein thrombosis, i.e. not arising by contiguous extension of a thrombus in the calf.

Contemporary best practice in the management of pulmonary embolism during pregnancy

Management of pregnancy-related VTE is challenging and data are limited. Guidelines vary and base their recommendations on low quality evidence. We conclude that the pregnancy-adapted YEARS diagnostic algorithm is well tolerated and the most efficient diagnostic algorithm for pregnant women with suspected PE. LMWH is the first-choice anticoagulant treatment in pregnancy and should be continued until 6 weeks postpartum and with a minimum of 3 months. Thrombolysis and the use of IVC filters are not routinely recommended in pregnancy as there is less experience and evidence but could be considered in selected cases.

Management of high-risk pulmonary embolism in pregnancy

Pregnancy-associated high-risk pulmonary embolism (PE) is among the most frequent causes of maternal mortality in the Western world, by causing hemodynamic instability and circulatory failure through a large thrombotic pulmonary obstruction. The very challenging management of these dramatic situations comprises the need to quickly select a therapy of pulmonary reperfusion or hemodynamic replacement, while taking into account both maternal and fetal risks.

Pregnancy-Related Thromboembolism—Current Challenges at the Emergency Department

The primary treatment for acute VTE during pregnancy and the post-partum period is anticoagulation. The selection of the anticoagulant agent is determined by a few factors, including the anatomical location, extension and severity of the thrombosis, the gestational age, and the possible risks to the fetus. Heparin, preferably LMWH, is to be used, although UFH can be used as well, since neither agent crosses the placental barrier. This differs from anti-vitamin K oral anticoagulant (AVK) warfarin that can cross the placenta and has the potential to cause severe complications, such as stillbirth, miscarriage, teratogenicity, pregnancy loss, neurodevelopmental deficits, and excessive bleeding. Nonetheless, warfarin can be used during breastfeeding. The direct oral anticoagulants (DOACs) pass through the placenta and are not recommended in pregnancy. Moreover, LMWH is preferred as a first-line treatment for preventing and treating VTE in pregnancy instead of UFH because it exhibits a lower risk of adverse effects, such as hemorrhage, osteoporosis, heparin-induced thrombocytopenia and allergic reactions.

Pulmonary Embolism and Pregnancy—Challenges in Diagnostic and Therapeutic Decisions in High-Risk Patients

The diagnostic management of PE in pregnancy is particularly challenging due to the fact that pregnant women often have clinical symptoms, such as shortness of breath or tachycardia, which could point to the suspicion of PE, but can also be present as physiological changes during pregnancy.

Pulmonary Embolism in Pregnancy: A Review for Clinical Practitioners

Treatment of pregnancy-associated PE should be continued for at least three months, including six weeks postpartum. The discussion about anticoagulant therapy duration in pregnant women is controversial due to the paucity of available data. Hormonal contraceptives (such as birth control pills) can be continued during anticoagulant treatment to prevent pregnancy and mitigate the risk of abnormal uterine bleeding. Current evidence suggests that there is no increased risk of recurrent PE in women receiving combined hormonal or progestin-only contraceptives during anticoagulation.

Pulmonary Embolism in Pregnancy: Diagnostic Dilemmas

The symptoms of PE have a significant clinical overlap with normal changes seen in pregnancy. Tachycardia, shortness of breath, leg edema and GERD which are normal signs and symptoms in pregnancy mimic a DVT/PE. This overlap creates a diagnostic dilemma. Compression ultrasound is the test of choice to diagnose DVT in pregnant women. The rationale for performing a leg ultrasound in a pregnant woman with suspected DVT is that if DVT is confirmed, this leads to the same therapy as PE, and consequently chest imaging can be avoided altogether. This has the benefit of avoiding unnecessary radiation.

Pulmonary embolism management in the emergency department: part 2

Pulmonary embolism (PE) can present with a range of severity. Prognostic risk stratification is important for efficacious and safe management. This second of two review articles discusses the management of high-, intermediate- and low-risk PE. We discuss strategies to identify patients suitable for urgent outpatient care in addition to identification of patients who would benefit from thrombolysis. We discuss specific subgroups of patients where optimal treatment differs from the usual approach and identify emerging management paradigms exploring new therapies and subgroups.

Pulmonary thrombo-embolism in pregnancy: diagnosis and management

The mainstay of treatment for pulmonary thromboembolism in pregnancy is anticoagulation with low molecular weight heparin for a minimum of 3 months in total duration and until at least 6 weeks postnatal. Low molecular weight heparin is safe, effective and has a low associated bleeding risk.

Treatment options for severe pulmonary embolism during pregnancy and the postpartum period: a systematic review

Published cases of thrombolysis for massive PE during pregnancy and the postpartum period suggest a high maternal and fetal survival (94% and 88%). In the postpartum period, given the high risk of major bleeding with thrombolysis, other therapeutic options (catheter [or surgical] thrombectomy, ECMO) may be considered if available.