image by: AcepNow

HWN Suggests

Decoding Pulmonary Embolism Evaluation in Pregnancy

The important thing to remember is that if you think of PE as a diagnosis you need an approach to confidently exclude or diagnose. - Emergency Care Institute... The Good News - Over the past few years, recent studies have provided evidence that many pregnant patients can be risk-stratified and have PE excluded without the need for imaging. A 2018 study by Righini and colleagues found that an algorithm combining the Revised Geneva Score (RGS), lower-extremity ultrasound, computed tomographic pulmonary angiogram and/or V/Q scan, and D-dimer resulted in no missed cases of symptomatic venous thromboembolism at three months. Meanwhile, imaging was avoided in 11.6 percent of the 367 cases. At nearly…

read full article

Featured

 Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism

In conclusion, the pregnancy-adapted YEARS diagnostic algorithm safely ruled out acute pulmonary embolism in pregnant patients who were referred for suspected pulmonary embolism. The main advantage of this approach was that CT pulmonary angiography was averted in 32 to 65% of the patients, depending on the trimester of presentation, without compromising safety.

 Pregnancy-Adapted YEARS Algorithm for PE – Ready for Prime Time?

External validation of this approach is needed but, application of the pregnancy-adapted YEARS algorithm has the potential to safely decrease CTPA use in pregnant women in whom the clinician has a concern for PE.

 Pulmonary Embolism In Pregnancy

Diagnosing a pulmonary embolism (PE) in a pregnant patient is a situation that requires clinicians to employ a high index of suspicion. According to the Centers for Disease Control and Prevention (CDC), PE in pregnancy accounts for 20% of maternal deaths in the United States. The presentation is complicated by the fact that symptoms commonly associated with PE in the non-pregnant population can be caused by normal physiologic changes of pregnancy.

Articles of Interest

Again With the Failings of CTPA

Most of the unhinged ramblings on this blog involve lamenting the excessive sensitivity of CT pulmonary angiograms for the diagnosis of pulmonary embolism.

CTPA – Is This Test Just a Little Too Good?

Our ability to detect PEs has increased over time, but with hypersensitive testing we risk overdiagnosis, which can cause more harm than good.

D-Dimer and Pregnancy: The DiPEP Study

While the use of the D-dimer in conjunction with a low pre-test probability for pulmonary embolism is well established for ruling out PE in the non-pregnant population, the preponderance of evidence to date suggests significant shortcomings with such a strategy in pregnant patients. Among pregnant women presenting with concern for pulmonary embolism in pregnancy, there remain no data supporting the use of D-dimer in any diagnostic algorithm.

D-Dimer to Rule Out Venous Thromboembolism During Pregnancy: A Systematic Review and Meta-Analysis

The majority of clinical guidelines recommend the D-dimer should not be used to assess the risk of VTE in pregnant women. However, CTPE presents a radiation risk to both the mother and fetus. Unfortunately, most VTE studies exclude pregnant women. Recent studies have identified D-dimer as accurate measure or risk of VTE in conjunction with a clinical decision rule to identify those at low risk of VTE.

Diagnosis of Pulmonary Embolism during Pregnancy

Although rare, pulmonary embolism (PE) remains one of the most common causes of severe maternal morbidity and mortality during pregnancy. Among pregnant women with suspected PE, the prevalence of confirmed disease is far lower than in the general population, reflecting the fear of missing the diagnosis and a low threshold to suspect PE in this setting. Two prospective management outcome trials have recently assessed two different diagnostic algorithms based on the assessment of clinical probability, D-dimer, venous compression ultrasonography of the lower limbs (CUS), and computed tomography pulmonary angiography (CTPA).

Diagnosis of Pulmonary Embolism during Pregnancy

The diagnosis of pulmonary embolism during pregnancy is difficult as clinical presentation may be misleading and few prospective data is available.

Diagnosis of Pulmonary Embolism During Pregnancy: A Multicenter Prospective Management Outcome Study

A diagnostic strategy based on assessment of clinical probability, D-dimer measurement, CUS, and CTPA can safely rule out PE in pregnant women.

Diagnostic Management of Pregnant Women With Suspected Pulmonary Embolism

Pulmonary embolism (PE) is one of the most common causes of severe morbidity and mortality during pregnancy. PE diagnosis during pregnancy remains a true challenge for all physicians, as many of the symptoms and signs associated with PE are often reported during physiological pregnancy. The fear of missing a PE during pregnancy leads a low threshold of suspicion, hence to a low prevalence of confirmed PE among pregnant women with suspected PE. This means that most pregnant women with suspected PE do not have the disease. Until recently, international guidelines suggested thoracic imaging in all pregnant women with suspected PE. Two recent prospective management outcome studies based on clinical probability assessment, D-dimer measurement, venous compression ultrasonography of the lower limbs (CUS) and computed tomography pulmonary angiography (CTPA) proved the safety of such strategies, with a very low failure rate.

Pregnancy-adapted YEARS Algorithm: A Retrospective Analysis

The use of the pregnancy-adapted YEARS algorithm could have resulted in decreased utilization of CTPA in the workup of PE in pregnant patients, and the algorithm showed similar reductions compared to prospective studies done in Europe. The pregnancy-adapted YEARS algorithm was also shown to be similar to the clinical rationale used by clinicians in the evaluation of pregnant patients, which indicates its potential for widespread acceptance into clinical practice.

Pregnancy-adapted YEARS algorithm: can YEARS do more for pregnant women?

Diagnosing PE in pregnancy is still a challenge. The choice of diagnostic method that would achieve the greatest benefit and do least harm in pregnancy is still under consideration. CUS is certainly the safest method for pregnant women. Results of the study by van der Pol et al. indicate high certainty in ruling out PE and high efficiency in reducing the need for CTPA. Application of this algorithm, with possible additional modifications according to local protocols, would improve the current diagnostic procedure in pregnant women.

Pulmonary Embolism - PE - Evaluation in the pregnant patient

Difficulty and confusion arises in the work up of PE in the pregnant patient due to 3 things: The normal physiological changes in pregnancy; dyspnoea, tachycardia and leg swelling are also symptoms that a patient with a PE can present with. The pre-test probability score, Wells Criteria cannot be used in a pregnant patient as they were excluded from the analysis group for criteria validation. The d-dimer will start to rise in the second trimester and remain elevated for 4-6 weeks post-partum.

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 Workup in Pregnancy

Since this recording, the first ever multi-center prospective outcome study looking at the pulmonary embolism workup in pregnancy was published in the Annals of Internal Medicine. A suggested algorithm and analysis of the study by Lauren Westafer are provided in these show notes….

Pulmonary Embolism Workup in Pregnancy

We have Dr. Elisha Targonsky, Emergency Physician at North York General Hospital tell his Best Case Ever that elucidates the practical challenges of working up pregnant patients in the ED with a suspicion of pulmonary embolism.

Pulmonary Embolism Workup in Pregnancy: Is D-dimer a Thing?

The workup of pregnant patients for PE is complicated. Pregnancy is considered a risk factor for PE. However, the algorithms and risk stratification tools widely used excluded pregnant patients in the development phase. Additionally, the use of the d-dimer in pregnancy is controversial in pregnancy. It's known that the d-dimer rises through pregnancy, making the utility questionable. While some have attempted to determine gestational age adjusted d-dimer cut offs and one expert recommends a first trimester cutoff of 750 ng/mL, a second trimester, cutoff of 1000 ng/mL, and a third trimester cut off of 1250 ng/mL, this has not been formally studied in PE[2,3]. Further, the risks of the objective tests in the patients may be greater due to radiation to the fetus and maternal breast tissue.

PURLs: Ruling out PE in pregnancy

Can clinical probability and a high-sensitivity D-dimer test reliably and safely rule out pulmonary embolism during pregnancy?