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Moroi ȘI, Weiss E, Stanciu S, Bădilă E, Ilieșiu AM, Balahura AM. Pregnancy-Related Thromboembolism-Current Challenges at the Emergency Department. J Pers Med 2024; 14:926. [PMID: 39338180 PMCID: PMC11433414 DOI: 10.3390/jpm14090926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Revised: 08/27/2024] [Accepted: 08/29/2024] [Indexed: 09/30/2024] Open
Abstract
Thrombotic events during pregnancy are burdened by an increased risk of morbidity and mortality, despite innovations in their diagnosis and treatment. Given their multifactorial etiology, it is important to understand all the pathophysiological mechanisms but especially to achieve correct and timely diagnosis. Pulmonary embolism (PE) during pregnancy represents a rare event, with an incidence of 1 per 1000 pregnancies, but it is also one of the leading causes of death during pregnancy. Managing PE in the acute setting is even more challenging and complex due to the attempt to maintain a balance between hemorrhagic and thrombotic complications while ensuring an optimal outcome for both the mother and the baby. In this review, our aim is to analyze the most significant challenges of acute PE during pregnancy and identify suitable management approaches for specific situations in order to improve the prognosis of pregnant women.
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Affiliation(s)
- Ștefan-Ionuț Moroi
- Department of Cardiology, Emergency Institute for Cardiovascular Diseases "Prof. Dr. C.C. Iliescu", 022328 Bucharest, Romania
| | - Emma Weiss
- "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Internal Medicine Department, Bucharest Clinical Emergency Hospital, 014461 Bucharest, Romania
| | - Silviu Stanciu
- "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Dr. Carol Davila University Central Military Emergency Hospital, Calea Plevnei 134, 010825 Bucharest, Romania
| | - Elisabeta Bădilă
- "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Cardiology, Colentina Hospital, 020125 Bucharest, Romania
| | - Adriana Mihaela Ilieșiu
- "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Cardiology, "Prof. Dr. Theodor Burghele" Clinical Hospital, 061344 Bucharest, Romania
| | - Ana-Maria Balahura
- "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Cardiology, "Prof. Dr. Theodor Burghele" Clinical Hospital, 061344 Bucharest, Romania
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Makowska A, Treumann T, Venturini S, Christ M. Pulmonary Embolism in Pregnancy: A Review for Clinical Practitioners. J Clin Med 2024; 13:2863. [PMID: 38792409 PMCID: PMC11121909 DOI: 10.3390/jcm13102863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
Diagnostic and therapeutic decision-making in pregnancy with suspected pulmonary embolism (PE) is challenging. European and other international professional societies have proposed various recommendations that are ambiguous, probably due to the unavailability of randomized controlled trials. In the following sections, we discuss the supporting diagnostic steps and treatments. We suggest a standardized diagnostic work-up in pregnant patients presenting with symptoms of PE to make evidence-based diagnostic and therapeutic decisions. We strongly recommend that clinical decisions on treatment in pregnant patients with intermediate- or high-risk pulmonary embolism should include a multidisciplinary team approach involving emergency physicians, pulmonologists, angiologist, cardiologists, thoracic and/or cardiovascular surgeons, radiologists, and obstetricians to choose a tailored management option including an interventional treatment. It is important to be aware of the differences among guidelines and to assess each case individually, considering the specific views of the different specialties. This review summarizes key concepts of the diagnostics and acute management of pregnant women with suspected PE that are supportive for the clinician on duty.
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Affiliation(s)
- Agata Makowska
- Emergency Department, Cantonal Hospital Lucerne, 6000 Lucerne, Switzerland; (S.V.); (M.C.)
- Cardiology, Hospital Centre of Biel, 2501 Biel, Switzerland
| | - Thomas Treumann
- Radiology, Cantonal Hospital Lucerne, 6000 Lucerne, Switzerland;
| | - Stefan Venturini
- Emergency Department, Cantonal Hospital Lucerne, 6000 Lucerne, Switzerland; (S.V.); (M.C.)
| | - Michael Christ
- Emergency Department, Cantonal Hospital Lucerne, 6000 Lucerne, Switzerland; (S.V.); (M.C.)
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Bhangu G, Murray A, Qayyum A, Goumeniouk N, Goodacre S, Hunt BJ, Touhami O, Tester J, Rees M, Hammerschlag G, Pascoe D, Ronksley PE, King JA, Choi H, McDermott S, Le Gal G, Skeith L. Diagnostic strategies in postpartum individuals with suspected venous thromboembolism: A scoping review. Thromb Res 2024; 236:108-116. [PMID: 38422980 DOI: 10.1016/j.thromres.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/02/2024] [Accepted: 02/13/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND The risk of venous thromboembolism (VTE) is increased postpartum and contributes to important morbidity and mortality. While there have been advances in evaluating diagnostic algorithms for suspected VTE during pregnancy, there is limited data for postpartum individuals. OBJECTIVE We conducted a scoping review to describe and evaluate diagnostic strategies used to investigate suspected VTE in postpartum individuals. METHODS A comprehensive search strategy was conducted in Ovid MEDLINE, Embase and the Cochrane Central Register of Controlled Trials (January 1, 2000-September 30, 2022) to identify original articles that reported on diagnostic strategies in postpartum individuals with suspected VTE. We extracted demographics, clinical decision rules used, D-dimer and imaging completed, including test performance and VTE outcomes. RESULTS A total of 13 studies conducted across 11 countries with separate postpartum data were included for 759 individuals with suspected PE (n = 634) or DVT (n = 125), including unpublished data (n = 251). Among those with suspected PE, computed tomography pulmonary angiography was conducted more commonly (n = 522) than ventilation-perfusion scans (n = 69), with PE positivity rates that ranged from 4 %-27.6 % and 0-50 % across studies, respectively. Among 131 postpartum individuals with suspected PE who had a D-dimer measured, only 4.6 % (6/131) had a negative D-dimer test. For postpartum individuals with suspected DVT, the most common diagnostic test was compression ultrasonography (positivity rate 12.2 %-18.6 %). There were limited retrospective data evaluating the clinical decision rules. CONCLUSIONS There are heterogeneous approaches globally in the diagnosis of suspected postpartum VTE. Limited high-quality data available underscores the need for more robust evidence to inform clinical practice.
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Affiliation(s)
- Gurjeet Bhangu
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Alistair Murray
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Areeb Qayyum
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Natasha Goumeniouk
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Steve Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Beverley J Hunt
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Omar Touhami
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Hôpital Charles-LeMoyne, Sherbrooke University, Quebec, Canada
| | - Jodie Tester
- Department of Respiratory Medicine and Sleep Disorders, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Megan Rees
- Department of Respiratory Medicine and Sleep Disorders, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Gary Hammerschlag
- Department of Respiratory Medicine and Sleep Disorders, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Diane Pascoe
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia; Department of Radiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Paul E Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - James A King
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Alberta SPOR Support Unit Data Platform, Alberta Health Services, Calgary, Alberta, Canada
| | - Hyun Choi
- Emergency Department, University Hospital Lewisham, London, United Kingdom
| | - Shaunagh McDermott
- Thoracic Imaging Division, Department of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | - Gregoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Leslie Skeith
- Department of Medicine, University of Calgary, Calgary, AB, Canada; Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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Stals MAM, Moumneh T, Ainle FN, Aujesky D, van Bemmel T, Bertoletti L, Bistervels IM, Chauleur C, Couturaud F, van Dooren YPA, Elias A, Faber LM, Le Gall C, Hofstee HMA, van der Hulle T, Kruip MJHA, Maignan M, Mairuhu ATA, Middeldorp S, Le Moigne E, Nijkeuter M, van der Pol LM, Robert-Ebadi H, Roy PM, Sanchez O, Schmidt J, van Smeden M, Tromeur C, Wolde MT, Righini M, Le Gal G, Huisman MV, Klok FA. Noninvasive diagnostic work-up for suspected acute pulmonary embolism during pregnancy: a systematic review and meta-analysis of individual patient data. J Thromb Haemost 2023; 21:606-615. [PMID: 36696189 DOI: 10.1016/j.jtha.2022.11.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 11/11/2022] [Accepted: 11/15/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Few studies evaluated the performance of noninvasive diagnostic strategies for suspected acute pulmonary embolism (PE) in pregnant women. OBJECTIVES The aim of this study was to establish the safety and efficiency of the Wells rule with fixed and adapted D-dimer threshold, and the YEARS algorithm, combined with compression ultrasonography (CUS), in pregnant women with suspected PE in an individual patient data meta-analysis. METHODS We performed a systematic review to identify prospective diagnostic management studies in pregnant women with suspected PE. Primary outcomes were safety, defined as the failure rate, ie, the 3-month venous thromboembolism (VTE) incidence after excluding PE without chest imaging, and efficiency, defined as the proportion of patients in whom chest imaging could be avoided. RESULTS We identified 2 relevant studies, of which individual patient-level data were analyzed in a fixed-effect meta-analysis, totaling 893 pregnant women. The Wells rule with fixed and adapted D-dimer threshold as well as the YEARS algorithm could safely rule out acute PE (failure rate, 0·37%-1·4%), but efficiency improved considerably when applying pretest probability-adapted D-dimer thresholds. The efficiency of bilateral CUS was limited (2·3% overall; number needed to test 43), especially in patients without symptoms of deep-vein thrombosis (efficiency 0·79%; number needed to test 127). CONCLUSION This study supports the latest guideline recommendations (European Society of Cardiology 2019) to apply pretest probability assessment and D-dimer tests to rule out PE in pregnant women. From an efficiency perspective, the use of a strategy with pretest probability-adapted D-dimer threshold is preferred. The yield of CUS was very limited in patients without concomitant symptoms of deep-vein thrombosis.
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Affiliation(s)
- Milou A M Stals
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Thomas Moumneh
- Department of Emergency Medicine, CHU Angers, University Hospital of Angers, UMR MitoVasc CNRS 6015 - INSERM 1083, Equipe CARME, Angers, France; F-CRIN INNOVTE research network, Saint-Etienne, France
| | - Fionnuala Ni Ainle
- Department of Hematology, Mater Misericordiae University Hospital, Dublin, and School of Medicine, University College Dublin, Ireland
| | - Drahomir Aujesky
- Division of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas van Bemmel
- Department of Internal Medicine, Gelre Ziekenhuizen Apeldoorn, Apeldoorn, the Netherlands
| | - Laurent Bertoletti
- F-CRIN INNOVTE research network, Saint-Etienne, France; Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France; CIC 1408 Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France University Jean Monnet, University Hospital of Saint-Etienne, Mines Saint-Etienne, INSERM U 1059, Saint-Etienne, France
| | - Ingrid M Bistervels
- Department of Internal Medicine, Flevo Hospital, Almere, the Netherlands; Department of Vascular Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Céline Chauleur
- Department of Obstetrics and Gynaecology, CHU de St-Etienne, Saint-Etienne, France; CIC 1408 Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France University Jean Monnet, University Hospital of Saint-Etienne, Mines Saint-Etienne, INSERM U 1059, Saint-Etienne, France
| | - Francis Couturaud
- F-CRIN INNOVTE research network, Saint-Etienne, France; Department of Internal Medicine and Chest Diseases, Brest Hospital Center, Groupe d'Etude de Thrombose de Bretagne Occidentale, INSERM UMR1304, University of Brest, Brest, France
| | | | - Antoine Elias
- F-CRIN INNOVTE research network, Saint-Etienne, France; Médecine Vasculaire, Centre Hospitalier de Toulon, Toulon, France
| | - Laura M Faber
- Department of Internal Medicine, Red Cross Hospital, Beverwijk, the Netherlands
| | - Catherine Le Gall
- F-CRIN INNOVTE research network, Saint-Etienne, France; Centre Hospitalier d'Argenteuil, Argenteuil, France
| | - Herman M A Hofstee
- Department of Internal Medicine, Haaglanden Medical Center, The Hague, the Netherlands
| | - Tom van der Hulle
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Marieke J H A Kruip
- Department of Hematology Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Maxime Maignan
- Department of Emergency, CHU Grenoble-Alpes, Hypoxy-Physiopathology laboratory HP2, Grenoble, France
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands
| | - Saskia Middeldorp
- Department of Internal Medicine and Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Emmanuelle Le Moigne
- F-CRIN INNOVTE research network, Saint-Etienne, France; Department of Internal Medicine and Chest Diseases, Brest Hospital Center, Groupe d'Etude de Thrombose de Bretagne Occidentale, INSERM UMR1304, University of Brest, Brest, France
| | - Mathilde Nijkeuter
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Liselotte M van der Pol
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Helia Robert-Ebadi
- F-CRIN INNOVTE research network, Saint-Etienne, France; Department of Medicine, Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Pierre-Marie Roy
- Department of Emergency Medicine, CHU Angers, University Hospital of Angers, UMR MitoVasc CNRS 6015 - INSERM 1083, Equipe CARME, Angers, France; F-CRIN INNOVTE research network, Saint-Etienne, France
| | - Olivier Sanchez
- F-CRIN INNOVTE research network, Saint-Etienne, France; Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Jeannot Schmidt
- F-CRIN INNOVTE research network, Saint-Etienne, France; Department of Emergency, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Maarten van Smeden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Cecile Tromeur
- F-CRIN INNOVTE research network, Saint-Etienne, France; Department of Internal Medicine and Chest Diseases, Brest Hospital Center, Groupe d'Etude de Thrombose de Bretagne Occidentale, INSERM UMR1304, University of Brest, Brest, France
| | - Marije Ten Wolde
- Department of Internal Medicine, Flevo Hospital, Almere, the Netherlands
| | - Marc Righini
- Department of Medicine, Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Grégoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Thrombosis Research Group, Ottawa, Canada
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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Seliverstov E, Lobastov K, Ilyukhin E, Apkhanova T, Akhmetzyanov R, Akhtyamov I, Barinov V, Bakhmetiev A, Belov M, Bobrov S, Bozhkova S, Bredikhin R, Bulatov V, Vavilova T, Vardanyan A, Vorobiev N, Gavrilov E, Gavrilov S, Golovina V, Gorin A, Dzhenina O, Dianov S, Efremova O, Zhukovets V, Zamyatin M, Ignatiev I, Kalinin R, Kamaev A, Kaplunov O, Karimova G, Karpenko A, Kasimova A, Katelnitskaya O, Katelnitsky I, Katorkin S, Knyazev R, Konchugova T, Kopenkin S, Koshevoy A, Kravtsov P, Krylov A, Kulchitskaya D, Laberko L, Lebedev I, Malanin D, Matyushkin A, Mzhavanadze N, Moiseev S, Mushtin N, Nikolaeva M, Pelevin A, Petrikov A, Piradov M, Pikhanova Z, Poddubnaya I, Porembskaya O, Potapov M, Pyregov A, Rachin A, Rogachevsky O, Ryabinkina Y, Sapelkin S, Sonkin I, Soroka V, Sushkov S, Schastlivtsev I, Tikhilov R, Tryakin A, Fokin A, Khoronenko V, Khruslov M, Tsaturyan A, Tsed A, Cherkashin M, Chechulova A, Chuiko S, Shimanko A, Shmakov R, Yavelov I, Yashkin M, Kirienko A, Zolotukhin I, Stoyko Y, Suchkov I. Prevention, Diagnostics and Treatment of Deep Vein Thrombosis. Russian Experts Consensus. FLEBOLOGIIA 2023; 17:152. [DOI: 10.17116/flebo202317031152] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2024]
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Righini M, Robert-Ebadi H, Cremonesi A, Elias A, Sanchez O, Le Moigne E, Schmidt J, Le Gall C, Cornuz J, Aujesky D, Roy PM, Chauleur C, Rouyer F, Poletti PA, Moreau C, Le Gal G. Risk of neonatal hypothyroidism in newborns from mothers exposed to CTPA during pregnancy: Ancillary data from a prospective outcome study. J Thromb Haemost 2022; 20:2550-2555. [PMID: 35950611 DOI: 10.1111/jth.15843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 08/02/2022] [Accepted: 08/03/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Neonatal hypothyroidism is often raised as a potential concern for the use of computed tomography pulmonary angiography (CTPA) in pregnant women with suspected pulmonary embolism (PE). OBJECTIVES To assess the incidence of neonatal hypothyroidism among newborns from mothers exposed to CTPA. PATIENTS/METHODS Pregnant women with clinically suspected PE were included in a multicenter, multinational prospective diagnostic management outcome study, based on pretest clinical probability assessment, high-sensitivity D-dimer testing, bilateral lower limb venous compression ultrasonography, and CTPA. Results of Guthrie tests were systematically collected for newborns of all women who required CTPA as part of the diagnostic strategy. A thyroid-stimulating hormone (TSH) level above 15 U/ml was used to define hypothyroidism. RESULTS Out of the 166 women included in the Swiss participating centers, 149 underwent a CTPA including 14 with twin pregnancies. Eight women suffered a pregnancy loss and results of the Guthrie test could not be retrieved for four newborns. All TSH levels were reported as being below 15 U/ml. The incidence of neonatal hypothyroidism was 0/151 (0.0%, 95% confidence interval: 0.0%-2.5%). CONCLUSIONS We did not identify any cases of neonatal hypothyroidism in our cohort of 149 pregnant women investigated for suspected PE using a CTPA. Along with previous literature data, this provides further reassuring data regarding the use of CTPA in this indication.
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Affiliation(s)
- Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Alessio Cremonesi
- Division of Clinical Biochemistry and Swiss Newborn Screening, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Antoine Elias
- Médecine Vasculaire, Centre Hospitalier de Toulon, Toulon, France
| | - Olivier Sanchez
- Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- INSERM UMR S 1140, Paris, France
- F-CRIN INNOVTE, Saint-Etienne, France
| | | | - Jeannot Schmidt
- Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Jacques Cornuz
- Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Pierre-Marie Roy
- Department of Emergency Medicine, University Hospital of Angers, Angers, France
| | - Céline Chauleur
- INSERM U1059, Saint-Etienne, France
- University of Lyon, Saint-Etienne, France
- Department of Gynecology and Obstetrics, University Hospital, Saint-Etienne, France
| | - Frédéric Rouyer
- Division of Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | | | | | - Grégoire Le Gal
- EA3878 GETBO, Université de Brest, Brest, France
- Department of Hematology, Ottawa Health Research Institute, Ottawa, Ontario, Canada
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Diagnosis of Pulmonary Embolism during Pregnancy. Diagnostics (Basel) 2022; 12:diagnostics12081875. [PMID: 36010225 PMCID: PMC9406738 DOI: 10.3390/diagnostics12081875] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/26/2022] [Accepted: 07/28/2022] [Indexed: 11/16/2022] Open
Abstract
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). Both demonstrated the safety of such strategies to exclude PE, with a very low failure rate defined as the rate of subsequent 3-month venous thromboembolism in women left untreated after a negative work-up. These studies were also the first to prospectively demonstrate the safety of negative D-dimer associated with a clinical prediction rule to exclude PE without any chest imaging. Pregnant women are known to be a subgroup at particularly high risk of inappropriate diagnostic management, so the implementation of such validated diagnostic strategies in clinical practice should represent a high priority goal.
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Tester J, Rees M, Pascoe D, Earl V, Einsiedel P, Lim WK, Irving L, Hammerschlag G. Diagnostic imaging for suspected pulmonary embolism during pregnancy and postpartum: A comparative radiation dose study. J Med Imaging Radiat Oncol 2022; 67:223-231. [PMID: 35616173 DOI: 10.1111/1754-9485.13420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 04/20/2022] [Indexed: 12/13/2022]
Abstract
INTRODUCTION To compare the radiation dose exposure and diagnostic efficiency of computed tomographic pulmonary angiography (CTPA) and ventilation/perfusion imaging (V/Q) for clinically suspected pulmonary embolism (PE) in pregnant and postpartum women in a tertiary hospital setting. METHODS A retrospective cohort study of 473 pregnant and postpartum women referred for CTPA or V/Q for clinically suspected PE between January 2013 and December 2018 at a tertiary hospital. Maternal effective radiation dose, breast-absorbed radiation dose and fetal-absorbed dose estimates were calculated. Diagnostic yield was evaluated from radiological findings. RESULTS Computed tomographic pulmonary angiography (CTPA) was more commonly used for the imaging of suspected PE in pregnant and postpartum populations (51.9% vs. 48.1% and 77.1% vs. 22.9%, respectively). CTPA was associated with higher maternal effective and breast-absorbed doses (maternal effective CTPA 4.7 (±2.9) mSv (millisievert), V/Q 1.7(±0.8) mSv (mean difference 2.93 mSv P < 0.001), and breast-absorbed CTPA 8.0 (±5.2) mGy (milligray), V/Q 0.3 (±0.1) (mean difference 7.67 mGy P < 0.001), respectively). Fetal radiation dose exposure was low. The incidence of positive PE was 5.5%. Indeterminate rates of CTPA and V/Q were 3.0% and 5.5% (P = 0.176), respectively. CONCLUSIONS Compared to V/Q, CTPA is associated with higher maternal and breast radiation dose; however, modern CT scanners achieve lower radiation doses than historically described. Fetal radiation dose was comparably low. The diagnostic yield of the imaging modalities in pregnant and postpartum women is similar. Revision of guidelines should occur with the advances in CT technology.
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Affiliation(s)
- Jodie Tester
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Respiratory Medicine and Sleep Disorders, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Megan Rees
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Respiratory Medicine and Sleep Disorders, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Diane Pascoe
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Radiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Victoria Earl
- Department of Radiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Paul Einsiedel
- Department of Radiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Wen Kwang Lim
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Louis Irving
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Respiratory Medicine and Sleep Disorders, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Gary Hammerschlag
- Department of Respiratory Medicine and Sleep Disorders, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Hobohm L, Farmakis IT, Münzel T, Konstantinides S, Keller K. Pulmonary Embolism and Pregnancy-Challenges in Diagnostic and Therapeutic Decisions in High-Risk Patients. Front Cardiovasc Med 2022; 9:856594. [PMID: 35350540 PMCID: PMC8957783 DOI: 10.3389/fcvm.2022.856594] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 02/10/2022] [Indexed: 12/30/2022] Open
Abstract
Diagnosis of acute PE in pregnant women with haemodynamic instability is following the general integrated risk-adapted diagnostic algorithm and starts with bedside echocardiography to assess RV function. If RV dysfunction is identified, a prompt and immediate reperfusion without further imaging should be initiated. Although pregnancy is listed as a relative contraindication of systemic thrombolysis, in pregnant women with acute PE and haemodynamic instability thrombolysis must be considered. In those cases, other treatment strategies as surgical embolectomy or catheter-directed low-dose thromboylysis or percutaneous thrombectomy should be taken into consideration as well. A multidisciplinary team with experience of PE management in pregnancy should be consulted to reach consensus on the best treatment approach.
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Affiliation(s)
- Lukas Hobohm
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.,Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Ioannis T Farmakis
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany.,Department of Cardiology, Democritus University of Thrace, Komotini, Greece
| | - Karsten Keller
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.,Medical Clinic VII, University Hospital Heidelberg, Heidelberg, Germany
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10
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Robert-Ebadi H, Le Gal G, Righini M. Diagnostic Management of Pregnant Women With Suspected Pulmonary Embolism. Front Cardiovasc Med 2022; 9:851985. [PMID: 35369309 PMCID: PMC8967345 DOI: 10.3389/fcvm.2022.851985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/10/2022] [Indexed: 11/21/2022] Open
Abstract
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. For the first time, these studies also demonstrated that the association of a clinical prediction rule and D-dimer measurement allowed a safe exclusion of PE in a significant proportion of pregnant women, without the need for radiating imaging tests. These two prospective studies pave the way to further improvements in the diagnostic strategies. Indeed, both specific clinical prediction rules and possibly D-dimer cutoffs adapted to pregnant women could help to further reduce the proportion of patients needing thoracic imaging. As an imaging test will still ultimately be necessary in a significant proportion of women, further technical advances in CT scans protocols could reduce the radiation dose to both the fetus and the mother, an important step to reassure clinicians. Finally, educational efforts should be encouraged in the future to pass the challenge of implementing these validated diagnostic strategies in everyday clinical practice.
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Affiliation(s)
- Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- *Correspondence: Helia Robert-Ebadi
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
- EA3878 University of Brest, Brest, France
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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11
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Robert‐Ebadi H, Elias A, Sanchez O, Le Moigne E, Schmidt J, Le Gall C, Aujesky D, Roy P, Moumneh T, Chauleur C, Rouyer F, Le Gal G, Righini M. Assessing the clinical probability of pulmonary embolism during pregnancy: The Pregnancy-Adapted Geneva (PAG) score. J Thromb Haemost 2021; 19:3044-3050. [PMID: 34496121 PMCID: PMC9293232 DOI: 10.1111/jth.15521] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 09/02/2021] [Accepted: 09/07/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The diagnosis of pulmonary embolism (PE) in pregnant women represents an ongoing challenge. As in the general population, the first step in pregnant women with suspected PE consists of assessing clinical pre-test probability (PTP). However, no dedicated clinical decision rule has been developed in this population. OBJECTIVE To propose a new version of the Geneva score adapted to pregnant women with suspected PE. METHODS Data from a multicenter, prospective management outcome study including 395 women with suspected PE, in whom PTP was assessed using the Geneva score, were used. We first removed items which were present in none of the patients (cancer, age >65 years). Receiver operating characteristic (ROC) curve analysis was then performed for quantitative variables and the optimal threshold defined. The obtained Pregnancy-Adapted Geneva Score (PAG Score) comprised seven items, including an age 40 years or older and a heart rate >110 beats per minute. RESULTS The PAG Score showed a high discriminative power to identify patients with a low, intermediate, or high PTP, associated with increasing prevalence of PE, 2.3%, 11.6%, and 61.5%, respectively. The ROC curves showed an area under the curve of 0.795 for the PAG Score compared to 0.684 for the Geneva score. CONCLUSION In pregnant women with suspected PE, the PAG Score shows a high discriminative power to identify patients at low, intermediate, or high PTP. It has the strength of being a fully objective decision rule, is clinically relevant, easy to compute, and should now be tested in a prospective outcome study.
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Affiliation(s)
- Helia Robert‐Ebadi
- Division of Angiology and HemostasisFaculty of MedicineGeneva University Hospitals GenevaSwitzerland
| | - Antoine Elias
- Médecine vasculaireCentre Hospitalier de ToulonToulonFrance
- F‐CRIN INNOVTESaint‐EtienneFrance
| | - Olivier Sanchez
- F‐CRIN INNOVTESaint‐EtienneFrance
- Service de Pneumologie et Soins IntensifsHôpital Européen Georges Pompidou, AP‐HPUniversité de ParisParisFrance
- INSERM UMR S 1140ParisFrance
| | | | - Jeannot Schmidt
- F‐CRIN INNOVTESaint‐EtienneFrance
- Centre Hospitalier Universitaire de Clermont‐FerrandClermont‐FerrandFrance
| | - Catherine Le Gall
- F‐CRIN INNOVTESaint‐EtienneFrance
- Centre Hospitalier d’ArgenteuilArgenteuilFrance
| | - Drahomir Aujesky
- Department of General Internal MedicineBern University HospitalUniversity of BernBernSwitzerland
| | - Pierre‐Marie Roy
- F‐CRIN INNOVTESaint‐EtienneFrance
- Department of Emergency MedicineUNIV Angers, UMR MitoVasc (CNRS 6015 ‐ INSERM 1083)University Hospital of AngersAngersFrance
| | - Thomas Moumneh
- F‐CRIN INNOVTESaint‐EtienneFrance
- Department of Emergency MedicineUNIV Angers, UMR MitoVasc (CNRS 6015 ‐ INSERM 1083)University Hospital of AngersAngersFrance
| | - Céline Chauleur
- INSERM U1059Saint‐EtienneFrance
- University of LyonSaint‐EtienneFrance
- Department of Gynecology and ObstetricsUniversity HospitalSaint‐EtienneFrance
| | - Frederic Rouyer
- Emergency DepartmentGeneva University HospitalsGenevaSwitzerland
| | - Grégoire Le Gal
- Department of MedicineUniversity of OttawaOttawa Hospital Research InstituteOttawaOntarioCanada
- EA3878 University of BrestBrestFrance
| | - Marc Righini
- Division of Angiology and HemostasisFaculty of MedicineGeneva University Hospitals GenevaSwitzerland
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12
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Mehdipoor G, Jimenez D, Bertoletti L, Del Toro J, Fernández-Capitán C, Bura-Riviere A, Amado C, Valero B, Blanco-Molina Á, Otero R, Imbalzano E, Khorasani R, Prince MR, Bikdeli B, Monreal M. Imaging modalities for confirming pulmonary embolism during pregnancy: results from a multicenter international study. Eur Radiol 2021; 32:1238-1246. [PMID: 34331113 DOI: 10.1007/s00330-021-08161-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/01/2021] [Accepted: 06/18/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We explored the variations in use of imaging modalities for confirming pulmonary embolism (PE) according to the trimester of pregnancy. METHODS We included all pregnant patients with confirmed acute PE from RIETE, a prospective registry of patients with PE (03/2001-02/2020). Imaging modalities included computed tomography pulmonary angiography (CTPA), ventilation-perfusion (V/Q) scan, or presence of signs of acute PE along with imaging-confirmed proximal deep vein thrombosis (pDVT) without pulmonary vascular imaging. We compared the imaging modalities to postpartum patients with PE, and other non-pregnant women with PE. RESULTS There were 157 pregnant patients (age: 32.7 ± 0.5), 228 postpartum patients (age: 33.9 ± 0.5), and 23,937 non-pregnant non-postpartum women (age: 69.5 ± 0.1). CTPA was the most common modality for confirming PE, from 55.7% in first trimester to 58.3% in second trimester, and 70.0% in third trimester. From first trimester to third trimester, V/Q scanning was used in 21.3%, 16.7%, and 18.3% of cases, respectively. Confirmed pDVT along with the presence of signs/symptoms of PE was the confirmatory modality for PE in 21.3% of patients in first trimester, 19.4% in second trimester, and 6.7% in third trimester. The proportion of postpartum patients confirmed with CTPA (85.5%) was comparable to that of non-pregnant non-postpartum women (83.2%). From the first trimester of pregnancy to postpartum period, there was a linear increase in the proportion of patients with PE diagnosed with CTPA (p = 0.039). CONCLUSION CTPA was the primary modality for confirming PE in all trimesters of pregnancy, although its proportional use was higher in later stages of pregnancy. KEY POINTS • Computed tomography pulmonary angiography (CTPA) was the primary modality of diagnosis in all trimesters of pregnancy among patients with confirmed pulmonary embolism, even in the first trimester. • From the first trimester of pregnancy to postpartum period, there was a linear increase in the proportion of patients with pulmonary embolism who were diagnosed based on CTPA. • In the postpartum period, use of CTPA as the modality to confirm pulmonary embolism was comparable to non-pregnant patients.
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Affiliation(s)
- Ghazaleh Mehdipoor
- Department of Medicine, Peconic Bay Medical Center, Northwell Health, Riverhead, NY, USA
- Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- Medicine Department, Universidad de Alcalá, (IRYCIS), Madrid, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, Hôpital Nord, CHU de Saint-Etienne and INSERM U1059 SAINBIOSE - CIC 1408, Université Jean-Monnet, Saint-Etienne, France
| | - Jorge Del Toro
- Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Cristina Amado
- Department of Internal Medicine, Hospital Sierrallana, Santander, Spain
| | - Beatriz Valero
- Department of Internal Medicine, Hospital General Universitario de Alicante, Alicante, Spain
| | | | - Remedios Otero
- Department of Pneumonology, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Egidio Imbalzano
- Department of Clinical and Experimental Medicine, A.O.U Policlinico "G. Martino", Messina, Italy
| | - Ramin Khorasani
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Martin R Prince
- Department of Radiology, Weill Cornell Medical College and New York Presbyterian Hospital, New York, USA
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Behnood Bikdeli
- Cardiovascular Research Foundation (CRF), New York, NY, USA
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Manuel Monreal
- Department of Internal Medicine, Hospital de Badalona Germans Trias i Pujol, Badalona, Spain.
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13
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Rodriguez D, Jerjes-Sanchez C, Fonseca S, Garcia-Toto R, Martinez-Alvarado J, Panneflek J, Ortiz-Ledesma C, Nevarez F. Thrombolysis in massive and submassive pulmonary embolism during pregnancy and the puerperium: a systematic review. J Thromb Thrombolysis 2021; 50:929-941. [PMID: 32347509 DOI: 10.1007/s11239-020-02122-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Thrombolysis in high-risk pulmonary embolism (PE) patients is recommended worldwide; however, the evidence for thrombolysis during pregnancy and the immediate puerperium remains unclear. We conducted a systematic review from 1950 to 2019 through PubMed, Ovid/Willey, and Cochrane Library to assess the safety and effectiveness of thrombolysis during pregnancy and the immediate puerperium. Additionally, we characterized the clinical presentation, risk stratification, and diagnostic approach. We have communicated our results according to the PRISMA statement. We collected 141 records and, after critical assessment, included 47 case reports of 54 patients, including 43 and 11 patients during pregnancy and puerperium, respectively. During pregnancy, alteplase was the most frequent systemic thrombolytic agent used (67%), but only nine patients received the approved FDA regimen. With catheter-directed thrombolysis, low-dose thrombolytics and fragmentation were the most common regimens. Major bleeding occurred in 18% of cases, but there was no intracranial bleeding. One maternal death occurred secondary to refractory cardiogenic shock. Fetal mortality was 20%. During the immediate puerperium, nine patients received "off-label" first-, second-, and third-generation thrombolytic regimens, and four cases underwent catheter-directed thrombolysis. We observed nine major bleeding events, seven of which were from the uterine location and none of which were intracranial. In conclusion, overall, these data do not suggest prohibitive risk associated with thrombolysis for PE in pregnancy. Management of massive and high-risk submassive PE in pregnancy should be individualized to each patient. In the data presented, no fatal bleeding or intracranial bleeding was observed. Finally, future efforts should systematically collect and report data on high-risk PE in pregnancy and peripartum patients to improve the evidence-base clinical practice.
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Affiliation(s)
- David Rodriguez
- Escuela de Medicina y Ciencias de La Salud, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico
- Centro de Investigacion Biomedica del Hospital Zambrano Hellion, TecSalud, San Pedro Garza García, Nuevo Leon, Mexico
- Instituto de Cardiología y Medicina Vascular, TecSalud, San Pedro Garza García, Nuevo Leon, Mexico
| | - Carlos Jerjes-Sanchez
- Escuela de Medicina y Ciencias de La Salud, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico.
- Centro de Investigacion Biomedica del Hospital Zambrano Hellion, TecSalud, San Pedro Garza García, Nuevo Leon, Mexico.
- Instituto de Cardiología y Medicina Vascular, TecSalud, San Pedro Garza García, Nuevo Leon, Mexico.
- Hospital Zambrano Hellion, Batallón de San Patricio 112, Real San Agustin, San Pedro Garza Garcia, Nuevo Leon, 66278, Mexico.
| | - Sugely Fonseca
- Internal Medicine, Hospital San José, TecSalud, Nuevo Leon, Monterrey, Mexico
| | | | | | | | - Claudia Ortiz-Ledesma
- Escuela de Medicina y Ciencias de La Salud, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico
| | - Francisco Nevarez
- Escuela de Medicina y Ciencias de La Salud, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico
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14
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Blondon M, Martinez de Tejada B, Glauser F, Righini M, Robert-Ebadi H. Management of high-risk pulmonary embolism in pregnancy. Thromb Res 2021; 204:57-65. [PMID: 34146979 DOI: 10.1016/j.thromres.2021.05.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/24/2021] [Accepted: 05/29/2021] [Indexed: 12/30/2022]
Abstract
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. In this review, we discuss the role of risk stratification in pregnancy-associated PE and the available evidence to support the use of thrombolysis, catheter-directed thrombectomy/thrombolysis, surgical embolectomy and extracorporeal membrane oxygenation. Despite the lack of comparative studies and solid evidence, most reported cases of high-risk pregnancy-associated PE have been treated with thrombolysis, with high maternal and fetal survivals, and thrombolysis is suggested by guidelines in life-threatening PE. For women in the peripartum and early post-partum period, non-fibrinolytic treatments may be preferred as a first-line treatment, if available, because of the particularly high bleeding risk. In all cases, pregnancy-associated high-risk PE requires a multidisciplinary approach involving PE response teams and obstetricians.
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Affiliation(s)
- Marc Blondon
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
| | | | - Frederic Glauser
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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15
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Chan WS. Can pregnancy-adapted algorithms avoid diagnostic imaging for pulmonary embolism? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:184-189. [PMID: 33275675 PMCID: PMC7727560 DOI: 10.1182/hematology.2020000105] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
The low prevalence of pulmonary embolism (PE) among pregnant patients presenting with suspected PE implies that most of these patients will be found not have the disease. Given this low prevalence, excluding PE in this population has necessitated the use of sensitive and specific diagnostic imaging, such as computed tomography pulmonary angiography or ventilation-perfusion scanning. Recent studies suggest that a clinical prediction rule with D-dimer testing can also be used to exclude a subset of pregnant patients with suspected PE without the need for diagnostic imaging. The YEARS criteria, which consist of clinical signs and symptoms of deep venous thrombosis, hemoptysis, and PE as the most likely diagnosis (a subjective variable), combined with selective D-dimer levels, seem to safely exclude up to one-third of these patients without imaging. The revised Geneva rule using objective variables, combined with nonpregnancy cutoffs for D-dimer levels, offers some promise, although fewer patients avoided imaging (14%). These recent studies provide evidence in support of radiation avoidance for some patients; however, for most, imaging remains the only option. Future studies should focus on improving the safety and techniques of imaging modalities, in addition to improving the specificity of D-dimer testing and objective prediction rules. Studies assessing patients' and physicians' values, preferences, and risk perceptions are also required to assist clinicians in shared decision making when counseling pregnant patients with suspected PE.
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Affiliation(s)
- Wee-Shian Chan
- BC Women's Hospital, University of British Columbia, Vancouver, BC, Canada
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16
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Avila WS, Alexandre ERG, Castro MLD, Lucena AJGD, Marques-Santos C, Freire CMV, Rossi EG, Campanharo FF, Rivera IR, Costa MENC, Rivera MAM, Carvalho RCMD, Abzaid A, Moron AF, Ramos AIDO, Albuquerque CJDM, Feio CMA, Born D, Silva FBD, Nani FS, Tarasoutchi F, Costa Junior JDR, Melo Filho JXD, Katz L, Almeida MCC, Grinberg M, Amorim MMRD, Melo NRD, Medeiros OOD, Pomerantzeff PMA, Braga SLN, Cristino SC, Martinez TLDR, Leal TDCAT. Brazilian Cardiology Society Statement for Management of Pregnancy and Family Planning in Women with Heart Disease - 2020. Arq Bras Cardiol 2020; 114:849-942. [PMID: 32491078 PMCID: PMC8386991 DOI: 10.36660/abc.20200406] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Walkiria Samuel Avila
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | | | - Marildes Luiza de Castro
- Hospital das Clínicas da Faculdade de Medicina da Universidade Federal de Minas gerais (UFMG),Belo Horizonte, MG - Brasil
| | | | - Celi Marques-Santos
- Universidade Tiradentes,Aracaju, SE - Brasil
- Hospital São Lucas, Rede D'Or Aracaju,Aracaju, SE - Brasil
| | | | - Eduardo Giusti Rossi
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | - Felipe Favorette Campanharo
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM),São Paulo, SP - Brasil
- Hospital Israelita Albert Einstein,São Paulo, SP - Brasil
| | | | - Maria Elizabeth Navegantes Caetano Costa
- Cardio Diagnóstico,Belém, PA - Brasil
- Centro Universitário Metropolitano da Amazônia (UNIFAMAZ),Belém, PA - Brasil
- Centro Universitário do Estado Pará (CESUPA),Belém, PA - Brasil
| | | | | | - Alexandre Abzaid
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | - Antonio Fernandes Moron
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM),São Paulo, SP - Brasil
| | | | - Carlos Japhet da Mata Albuquerque
- Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, PE – Brazil
- Hospital Barão de Lucena, Recife, PE – Brazil
- Hospital EMCOR, Recife, PE – Brazil
- Diagnósticos do Coração LTDA, Recife, PE – Brazil
| | | | - Daniel Born
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM),São Paulo, SP - Brasil
| | | | - Fernando Souza Nani
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | - Flavio Tarasoutchi
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | - José de Ribamar Costa Junior
- Hospital do Coração (HCor),São Paulo, SP - Brasil
- Instituto Dante Pazzanese de Cardiologia,São Paulo, SP - Brasil
| | | | - Leila Katz
- Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, PE – Brazil
| | | | - Max Grinberg
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | | | - Nilson Roberto de Melo
- Departamento de Obstetrícia e Ginecologia da Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo, SP – Brazil
| | | | - Pablo Maria Alberto Pomerantzeff
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
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17
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Sutham K, Na-Nan S, Paiboonsithiwong S, Chaksuwat P, Tongsong T. Leg massage during pregnancy with unrecognized deep vein thrombosis could be life threatening: a case report. BMC Pregnancy Childbirth 2020; 20:237. [PMID: 32321459 PMCID: PMC7178622 DOI: 10.1186/s12884-020-02924-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 04/03/2020] [Indexed: 02/02/2023] Open
Abstract
Background Traditional massage seems to be safe but not entirely risk free, though serious adverse events are very rare. This report is aimed at illustrating a rare but fatal presentation of massive pulmonary embolism caused by leg massage and also to encourage both massage providers and pregnant women to be aware of undetected or subtle deep vein thrombosis, which could be a life threatening condition as a consequence of leg massage. Case presentation A 25-year-old primigravid Thai woman underwent massage at a traditional massage shop at 25th week of gestation. Shortly after leg and foot massage, she had a sudden onset of dyspnea, followed by consciousness alteration, brief spastic-like convulsion, became unconscious and suffered a cardiac arrest. Basic life support (BLS) at the event scene as well as during transfer and advanced cardiovascular life support (ACLS) at the hospital were provided, resulting in successful resuscitation but persistent coma. Bedside echocardiography showed poor contractility of the dilated right ventricle, and pulmonary embolism was suspected. CT angiography (CTA) revealed multiple concentric intraluminal filling defects within the right and left pulmonary arteries, indicating massive pulmonary embolism. The fetus died in utero and spontaneous labor and vaginal delivery occurred. Conclusion Leg massage in patients with deep vein thrombosis can dislodge thrombi, leading to life threatening pulmonary embolism, and should be contraindicated. Since pregnant women are at a higher risk of undetected or subtle thromboembolism, traditional massage in pregnant women should be contraindicated unless they are proven to have no such risk.
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Affiliation(s)
| | | | | | - Pakorn Chaksuwat
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Theera Tongsong
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand.
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18
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Tester J, Hammerschlag G, Irving L, Pascoe D, Rees M. Investigation and diagnostic imaging of suspected pulmonary embolism during pregnancy and the puerperium: A review of the literature. J Med Imaging Radiat Oncol 2020; 64:505-515. [PMID: 32307898 DOI: 10.1111/1754-9485.13027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 02/16/2020] [Accepted: 02/23/2020] [Indexed: 11/27/2022]
Abstract
Pulmonary embolism (PE) is a leading cause of maternal mortality with women at increased risk of PE during pregnancy and the early postpartum period. Clinical assessment of suspected PE during pregnancy is challenging as signs and symptoms associated with PE overlap with physiological changes of pregnancy. Clinical tests and rules commonly used to assess pre-test probability of PE were historically not well validated in the pregnant population. The challenges of clinical assessment in the pregnant and postpartum population result in a lowered threshold for diagnostic imaging. Computed tomographic pulmonary angiography (CTPA) and nuclear medicine lung scintigraphy or ventilation/perfusion (V/Q) scans are the main types of diagnostic imaging for suspected PE. Both methods are associated with small levels of ionising radiation exposure to mother and foetus. Accuracy of the diagnostic imaging tests is paramount. Haemodynamic changes of pregnancy, including increased heart rate, increased blood volume and altered flow velocity in the pulmonary arteries, may influence the quality of imaging. This comprehensive review examines the literature and evidence for the investigation and diagnostic imaging of suspected pulmonary embolism during pregnancy with CTPA and V/Q. Clinical decision-making tools, biomarkers and diagnostic imaging during pregnancy and postpartum will be considered with a focus on diagnostic accuracy and yield, radiation dose exposure (maternal-foetal) and protocol modifications. Current practice guideline recommendations and recent literature on diagnostic pathways are also presented.
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Affiliation(s)
- Jodie Tester
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Gary Hammerschlag
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Louis Irving
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Diane Pascoe
- Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Radiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Megan Rees
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
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19
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Bokan A, Matijasevic J, Vucicevic Trobok J. Pregnancy-adapted YEARS algorithm: can YEARS do more for pregnant women? Breathe (Sheff) 2020; 16:190307. [PMID: 32194764 PMCID: PMC7078738 DOI: 10.1183/20734735.0307-2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Venous thromboembolism (VTE), as a term that encompasses pulmonary embolism (PE) and deep vein thrombosis (DVT), is one of the leading causes of maternal morbidity and mortality [1], especially in developed countries, where PE takes second place after complications of hypertensive disorders [2]. When compared to non-pregnant women of similar age, pregnant women have an approximately four to five times higher risk of VTE [3], with an incidence of 1 in 1000 pregnancies [4]. Approximately 20–25% of VTE cases are caused by PE and 75–80% of cases are caused by DVT [5]. About 60% of DVT occurs antepartum, with the highest risk of antepartum pregnancy-associated VTE being in the third trimester.However, about 60% of PE occurs postpartum [3]. Pregnancy-adapted YEARS algorithm provides high certainty in ruling out pulmonary embolism and high efficiency in reducing the need for CTPAhttp://bit.ly/2GgH4sv
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Rotzinger DC, Dunet V, Ilic V, Hugli OW, Meuli RA, Schmidt S. Pulmonary embolism during pregnancy: a 17-year single-center retrospective MDCT pulmonary angiography study. Eur Radiol 2020; 30:1780-1789. [PMID: 31728689 PMCID: PMC7033070 DOI: 10.1007/s00330-019-06501-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/23/2019] [Accepted: 10/08/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To determine the prevalence of pulmonary embolism (PE) and alternative diagnoses detected by computed tomography pulmonary angiography (CTPA) in pregnant women; and to assess changes over time regarding radiation dose, technical quality, and examination frequency. MATERIALS AND METHODS This retrospective study included all pregnant women referred for CTPA due to clinically suspected PE over 17 years. Two blinded radiologists reviewed the CTPAs in consensus with regard to PE, alternative diagnoses, and technical quality. We retrieved patient data regarding radiation dose metrics and associated clinical and laboratory parameters. Subgroup comparisons were performed (Wilcoxon and Kruskal-Wallis tests). RESULTS Of the 237 identified patients, 8 (3.3%) were excluded due to inadequate technical CTPA quality, and 229 patients were analyzed (mean age, 31.7 years; mean gestational age, 28 ± 7 weeks). The four different CT systems used over the study period had similar technical quality (p = 0.28). Of 229 patients 16 (7%) patients had PE, 144 (62.9%) had no abnormal findings, and 69 (30.1%) had an alternative diagnosis (consolidation, other pulmonary opacities, pleural effusion, and basal atelectasis). Gestational age, symptoms, and D-dimer levels were not significantly different between patients with or without PE (p > 0.05). Over time, radiation dose exposure decreased by 30% (p < 0.001), while the number of annual examinations increased by > 4-folds. CONCLUSIONS In pregnant women, CTPA rarely indicates PE and more often shows alternative diagnoses. Over 17 years, the use of CTPA in pregnancy has notably increased, while the radiation dose exposure has decreased by one third. KEY POINTS • The use of CTPA in pregnancy has steadily risen over the last 17 years • In pregnant women, CTPA rarely reveals PE and more often shows alternative diagnoses • Recent technical improvements have substantially decreased the radiation dose exposure inherent in CTPA without reducing diagnostic image quality.
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Affiliation(s)
- David C Rotzinger
- Department of Diagnostic and Interventional Radiology, Emergency Radiology Division, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland.
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland.
| | - Vincent Dunet
- Department of Diagnostic and Interventional Radiology, Emergency Radiology Division, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Vesna Ilic
- Centre d'Imagerie du Nord Vaudois (CINOV), Yverdon-les-Bains, Switzerland
| | - Olivier W Hugli
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
- Emergency Department, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Reto A Meuli
- Department of Diagnostic and Interventional Radiology, Emergency Radiology Division, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Sabine Schmidt
- Department of Diagnostic and Interventional Radiology, Emergency Radiology Division, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
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21
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Cohen SL, Feizullayeva C, McCandlish JA, Sanelli PC, McGinn T, Brenner B, Spyropoulos AC. Comparison of international societal guidelines for the diagnosis of suspected pulmonary embolism during pregnancy. LANCET HAEMATOLOGY 2020; 7:e247-e258. [PMID: 32109405 DOI: 10.1016/s2352-3026(19)30250-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/13/2019] [Accepted: 11/18/2019] [Indexed: 10/24/2022]
Abstract
Pregnancy-associated pulmonary embolism is one of the leading causes of maternal mortality. Diagnosis of pulmonary embolism in pregnancy is challenging, with symptoms of pulmonary embolism mimicking those of pregnancy. Several key components such as clinical prediction tools, risk stratification, laboratory tests, and imaging widely used for diagnosis of pulmonary embolism in the non-pregnant population show limitations for diagnosis in pregnancy. Further, because of the difficulty of studying pregnant patients, high-quality research evaluating the performance of these diagnostic components in pregnancy is scarce. Seven international medical society guidelines present clinical diagnostic pathways for evaluation of pulmonary embolism in pregnancy that show conflicting recommendations on the use of these diagnostic components. This Review assesses all key components of diagnostic clinical pathways recommended by guidelines for evaluation of pulmonary embolism in pregnancy, reviews current evidence, compares the guideline recommendations with respect to each key component, and provides our preferred diagnostic pathway. It provides the guidelines and available data needed for informed decision making to diagnose pulmonary embolism in pregnancy.
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Affiliation(s)
- Stuart L Cohen
- Imaging Clinical Effectiveness and Outcomes Research, Department of Radiology, Northwell Health, Manhasset, NY, USA; Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA.
| | - Chinara Feizullayeva
- Imaging Clinical Effectiveness and Outcomes Research, Department of Radiology, Northwell Health, Manhasset, NY, USA; Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - John A McCandlish
- Imaging Clinical Effectiveness and Outcomes Research, Department of Radiology, Northwell Health, Manhasset, NY, USA; Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA; Georgia Institute of Technology, Atlanta, GA, USA
| | - Pina C Sanelli
- Imaging Clinical Effectiveness and Outcomes Research, Department of Radiology, Northwell Health, Manhasset, NY, USA; Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Thomas McGinn
- Department of Medicine, Northwell Health, Manhasset, NY, USA; Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Benjamin Brenner
- Institute of Hematology, Rambam Health Care Campus and Technion, Israel Institute of Technology, Haifa, Israel; Department of Obstetrics and Gynaecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health, Manhasset, NY, USA; Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
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22
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Atallah D, Abou Zeid H, Moubarak M, Moussa M, Nassif N, Jebara V. "You only live twice": multidisciplinary management of catastrophic case in placenta Accreta Spectrum-a case report. BMC Pregnancy Childbirth 2020; 20:135. [PMID: 32111175 PMCID: PMC7048027 DOI: 10.1186/s12884-020-2817-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 02/18/2020] [Indexed: 01/12/2023] Open
Abstract
Background Placenta percreta is associated with high hemorrhagic risk and can be complicated with fatal thromboembolic events. Involving a multidisciplinary team in the treatment of these patients is mandatory to reduce morbidity and mortality. Case presentation This paper reports the case of a 22-year-old patient with placenta percreta who was referred to our tertiary care center for delivery. Few hours after undergoing a successful cesarean hysterectomy, the patient developed a pulmonary embolism and cardiac arrest. A transthoracic echocardiogram done in the intensive care unit (ICU) showed a thrombus in the right ventricle. After cardiac resuscitation, the patient underwent an urgent thoracotomy and a pulmonary artery thrombectomy; many clots were retrieved from the pulmonary artery. After weaning from extracorporeal circulation, an intraoperative transesophageal cardiac ultrasound enabled the medical team to detect a new free-floating thrombus in the right atrium and right ventricle, and consequently to perform an embolectomy and prevent the patient’s death. Conclusion This case emphasizes the role of multidisciplinary team in treating high-risk obstetric cases that could be complicated with massive and fatal thromboembolic events. The use of intraoperative transthoracic echocardiography helps in detecting a new thrombus and guides the anesthesiologist in the intra-operative monitoring.
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Affiliation(s)
- David Atallah
- Saint Joseph University, Beirut, Lebanon. .,Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, P.O. Box: 116-5137, Beirut, Lebanon.
| | - Hicham Abou Zeid
- Saint Joseph University, Beirut, Lebanon.,Department of Anesthesiology, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
| | - Malak Moubarak
- Saint Joseph University, Beirut, Lebanon.,Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, P.O. Box: 116-5137, Beirut, Lebanon
| | - Maya Moussa
- Saint Joseph University, Beirut, Lebanon.,Department of Anesthesiology, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
| | - Nadine Nassif
- Saint Joseph University, Beirut, Lebanon.,Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, P.O. Box: 116-5137, Beirut, Lebanon
| | - Victor Jebara
- Saint Joseph University, Beirut, Lebanon.,Department of Cardiovascular Surgery, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
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23
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Sun S, Diaconescu M, Zhe T, Mesurolle B, Semionov A. Outcomes of Multidetector Computed Tomography Pulmonary Angiography in Pregnant and Postpartum Women With Suspected Pulmonary Embolism. Can Assoc Radiol J 2020; 72:512-518. [PMID: 32070114 DOI: 10.1177/0846537119899552] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Verify whether there is a difference in likelihood of developing pulmonary embolism (PE) between pregnant women, nonpregnant women of reproductive age, and postpartum (up to 6 weeks) women, by comparing their outcomes on computed tomography pulmonary angiography (CTPA) done for suspicion of PE. MATERIALS AND METHODS Retrospective cohort study of 1463 CTPA done for suspicion of PE in females of reproductive age (18-40 years), nonpregnant, pregnant (antepartum), and postpartum, from 2 tertiary-care academic hospitals between October 2006 and September 2015. Primary outcome was diagnosis of PE on imaging. Additional assessment was made of technical adequacy of the studies and method of delivery for the postpartum cohort (vaginal vs caesarean birth). Twenty-nine technically nondiagnostic studies were excluded. The effect of any potential variable on PE status was tested using univariate logistic regression. Subgroup analysis was performed after excluding patients with independent risk factors for PE. RESULTS The rate of CTPA positive for PE was less among pregnant patients compared to early postpartum and nonpregnant women of similar age, 2.9% vs 11.5% and 10.3%, respectively. Pregnancy was associated with statistically significant decreased odds ratio of developing a PE on CTPA, 0.23 (0.09-0.89), P value = .004. After excluding patients with additional independent risk factors for PE, there was no statistically significant odds ratio association between presence of PE on CTPA and pregnancy 0.41 (0.13-1.34), P value = .14. CONCLUSION Rate of CTPA positive for PE in pregnant women was lower than in nonpregnant and early postpartum women. Pregnancy was statistically significantly less likely to be associated with positive PE on a CTPA study. The common perception that pregnancy (antepartum state) is associated with an increased risk of PE may require a thorough critical reappraisal.
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Affiliation(s)
- Simon Sun
- Department of Diagnostic Radiology, McGill University Health Centre, 10041Montreal General Hospital, Montréal, Quebec, Canada
| | - Marius Diaconescu
- Department of Diagnostic Radiology, McGill University Health Centre, 10041Montreal General Hospital, Montréal, Quebec, Canada
| | - Tian Zhe
- Cancer Prognostics and Health Outcomes Unit, CRCHUM, 5622University of Montreal Health Center, Montréal, Quebec, Canada
| | - Benoit Mesurolle
- Department of Radiology, 55046Centre République, Elsan, Clermont-Ferrand, France
| | - Alexandre Semionov
- Department of Diagnostic Radiology, McGill University Health Centre, 10041Montreal General Hospital, Montréal, Quebec, Canada
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24
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Wiegers HMG, Middeldorp S. Contemporary best practice in the management of pulmonary embolism during pregnancy. Ther Adv Respir Dis 2020; 14:1753466620914222. [PMID: 32425105 PMCID: PMC7238314 DOI: 10.1177/1753466620914222] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 02/25/2020] [Indexed: 12/25/2022] Open
Abstract
Approximately 1-2 per 1000 pregnancies are complicated by venous thromboembolism (VTE). VTE includes deep vein thrombosis (DVT) and pulmonary embolism (PE) and the diagnostic management of pregnancy-related VTE is challenging. Current guidelines vary greatly in their approach to diagnosing PE in pregnancy as they base their recommendations on scarce and weak evidence. The pregnancy-adapted YEARS diagnostic algorithm is well tolerated and is the most efficient diagnostic algorithm for pregnant women with suspected PE, with 39% of women not requiring computed tomographic pulmonary angiography. Low-molecular-weight heparin is the first-choice anticoagulant treatment in pregnancy and should be continued until 6 weeks postpartum and for a minimum of 3 months. Direct oral anticoagulants should be avoided in women who want to breastfeed. Management of delivery needs a multidisciplinary approach in order to decide on an optimal delivery plan. Neuraxial analgesia can be given in most patients, provided time windows since last low-molecular-weight heparin dose are respected. Women with a history of VTE are at risk of recurrence during pregnancy and in the postpartum period. Therefore, in most women with a history of VTE, thromboprophylaxis in subsequent pregnancies is indicated. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Hanke M. G. Wiegers
- Department of Vascular Medicine, Amsterdam UMC,
University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9,
Amsterdam, North Holland 1105 AZ, The Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam UMC,
University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The
Netherlands
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25
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Cohen SL, Wang JJ, Chan N, Feizullayeva C, McCandlish JA, O'Connell W, Sanelli P. Predictors of radiation dose for CT pulmonary angiography in pregnancy across a multihospital integrated healthcare network. Eur J Radiol 2019; 121:108721. [PMID: 31711025 DOI: 10.1016/j.ejrad.2019.108721] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 10/08/2019] [Accepted: 10/21/2019] [Indexed: 11/20/2022]
Abstract
PURPOSE There is a large range of published effective radiation dose for CTPA during pregnancy. The purpose of our study is to determine the mean effective radiation dose and predictors of mean effective radiation dose for CTPA in pregnant patients across a multihospital integrated healthcare network. METHODS This retrospective study evaluates pregnant women who had a CTPA as the first primary advanced imaging test for evaluation of PE in a multihospital integrated healthcare network from January 2012-April 2017. Patient and CT-related data were obtained from the electronic health record and Radimetrics server (Radimetrics Inc, Bayer). DLP was recorded and effective radiation dose in mSv was determined using a conversation factor of 0.014 mSv·mGy-¹·cm-¹. Patient size was determined by water equivalent diameter. Bivariate and multivariate analysis were performed for effective radiation dose based on patient and CT factors. RESULTS In the 534 CTPA exams, the mean effective radiation dose was 3.96 mSv. Bivariate analysis showed significant differences in radiation dose by trimester, p = 0.042: first trimester 4.52 mSv, second trimester 3.73 mSv, and third trimester 3.95 mSv. Multivariable analysis demonstrated CTPA during first trimester, increasing mAs, kVp, scan length, patient size, and use of mAs modulation, as well as decreasing pitch, to be predictive of higher effective radiation dose. CONCLUSION Mean effective radiation dose was on the lower end of published studies. Trimester was a statistically significant predictor of effective radiation dose when accounting for known predictors of radiation dose.
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Affiliation(s)
- Stuart L Cohen
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States; Northwell Health Imaging, Manhasset, NY, United States; Imaging Clinical Effectiveness & Outcomes Research Program at Northwell Health, Manhasset NY, United States; Feinstein Institute for Medical Research at Northwell Health, Manhasset NY, United States.
| | - Jason J Wang
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States; Imaging Clinical Effectiveness & Outcomes Research Program at Northwell Health, Manhasset NY, United States; Feinstein Institute for Medical Research at Northwell Health, Manhasset NY, United States
| | - Nicholas Chan
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Chinara Feizullayeva
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States; Northwell Health Imaging, Manhasset, NY, United States; Imaging Clinical Effectiveness & Outcomes Research Program at Northwell Health, Manhasset NY, United States; Feinstein Institute for Medical Research at Northwell Health, Manhasset NY, United States
| | | | - William O'Connell
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States; Northwell Health Imaging, Manhasset, NY, United States
| | - Pina Sanelli
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States; Northwell Health Imaging, Manhasset, NY, United States; Imaging Clinical Effectiveness & Outcomes Research Program at Northwell Health, Manhasset NY, United States; Feinstein Institute for Medical Research at Northwell Health, Manhasset NY, United States
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26
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Kim HY, Kim KH, Kim J, Park JC. Multimodality cardiovascular imaging in pulmonary embolism. Cardiol J 2019; 28:150-160. [PMID: 31478557 DOI: 10.5603/cj.a2019.0084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 08/20/2019] [Accepted: 08/20/2019] [Indexed: 11/25/2022] Open
Abstract
Acute pulmonary embolism (APE) is one of the leading causes of cardiovascular (CV) morbidity and mortality. To select appropriate therapeutic strategy and/or to minimize the mortality and morbidity, rapid and correct identification of life-threatening APE is very important. Also, right ventricular (RV) failure usually precedes acute hemodynamic compromise or death, and thus the identification of RV failure is another important step in risk stratification or treatment of APE. With advances in diagnosis and treatment, the prognosis of APE has been dramatically improving in most cases, but inadequate therapy or recurrent episodes of pulmonary embolism (PE) may result in negative outcomes or, so called, chronic thromboembolic pulmonary hypertension (CTEPH). CTEPH is a condition characterized by remaining chronic thromboembolic material in the pulmonary vasculature and subsequent chronic pulmonary hypertension. Various imaging modalities include chest computed tomography pulmonary angiography (CTPA), echocardiography, magnetic resonance imaging, and nuclear imaging and each are used for the assessment of varying status of PE. Assessment of thromboembolic burden by chest CTPA is the first step in the diagnosis of PE. Hemodynamic assessment can be achieved by echocardiography and also by chest CTPA. Nuclear imaging is useful in discriminating CTEPH from APE. Better perspectives on diagnosis, risk stratification and decision making in PE can be provided by combining multimodality CV imaging. Here, the advantages or pitfalls of each imaging modality in diagnosis, risk stratification, or management of PE will be discussed.
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Affiliation(s)
- Hyung Yoon Kim
- Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Kye Hun Kim
- Chonnam National University Hospital, Gwangju, Republic of Korea.
| | - Jahae Kim
- Department of Nuclear Medicine, Chonnam National University Hospital, Gwangju, Korea, Republic Of
| | - Jong Chun Park
- Chonnam National University Hospital, Gwangju, Republic of Korea
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27
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Lowe S. Diagnostic imaging in pregnancy: Making informed decisions. Obstet Med 2019; 12:116-122. [PMID: 31523267 PMCID: PMC6734637 DOI: 10.1177/1753495x19838658] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 02/26/2019] [Indexed: 01/03/2023] Open
Abstract
The use of diagnostic imaging involving ionising radiation may be necessary in pregnancy and requires an assessment of the most appropriate and safest imaging modality which will provide the necessary information balanced with the potential risks to the mother and fetus. In most cases, this will involve a potential fetal radiation dose well below 50 mGy. At these doses, there is no risk of lethality, genetic damage/epigenetic change, teratogenicity, growth impairment or sterility. Older epidemiological data indicating a potential increased cancer risk have been contradicted by newer data and better understanding of the biology of low dose radiation. The linear no-threshold rule has been challenged by many and more realistic estimates of oncogenicity risk along with the potential risks of contrast agents are summarised in this review. Imaging in the pregnant population is increasing in both the number of examinations performed and the number of patients being imaged, with the greatest increase being computed tomography scans. Counselling and obtaining informed consent for imaging that involves radiation requires the clinician to communicate with the woman and her family a realistic estimate of the potential radiation dose to herself and her fetus, to describe and quantitate the risks of this estimated dose, to outline the benefits of the imaging procedure and to respond to any questions or concerns. As almost all diagnostic imaging involves doses below the 50 mGy threshold, clinically indicated investigations should not be withheld during pregnancy. All allied staff must also be well informed to ensure the patient receives a consistent message about the risks and benefits of the proposed test.
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Affiliation(s)
- Sandra Lowe
- Royal Hospital for Women and School of Women’s and Children’s Health, University of New South Wales, Sydney, Australia
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28
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Chan K, Lang E. In pregnant women, the pregnancy-adapted YEARS algorithm ruled out PE, with a low rate of VTE at 3 months. Ann Intern Med 2019; 171:JC23. [PMID: 31426066 DOI: 10.7326/acpj201908200-023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | - Eddy Lang
- University of CalgaryCalgary, Alberta, Canada
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29
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Langlois E, Cusson-Dufour C, Moumneh T, Elias A, Meyer G, Lacut K, Schmidt J, Le Gall C, Chauleur C, Glauser F, Robert-Ebadi H, Righini M, Le Gal G. Could the YEARS algorithm be used to exclude pulmonary embolism during pregnancy? Data from the CT-PE-pregnancy study. J Thromb Haemost 2019; 17:1329-1334. [PMID: 31108013 DOI: 10.1111/jth.14483] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 05/13/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The recently proposed YEARS algorithm was shown to safely exclude pulmonary embolism (PE) and reduce the use of computed tomography pulmonary angiography (CTPA) among pregnant women with suspected PE. Our aim was to externally validate this finding. METHODS We performed a post hoc analysis of a prospective management outcome study for PE diagnosis in pregnant women. PE was diagnosed with an algorithm that combined the revised Geneva score, D-dimer testing, bilateral lower-limb compression ultrasonography, and CTPA. All women had a 3-month follow-up. All of the items necessary to use the YEARS algorithm were prospectively collected at the time of the study. RESULTS Of the 395 women included in the original study, 371 were available for the present analysis. The PE prevalence was 6.5%. Ninety-one women had no YEARS items, and 280 had one or more items. When the YEARS items were combined with D-dimer levels (<1000 ng/mL in women with no items, and <500 ng/mL in women with one or more items), 77 women (21%) met the criteria for PE exclusion and would not have undergone CTPA as per the YEARS algorithm. None of these 77 women had PE diagnosed during the initial work-up or 3-month follow-up. Therefore, the failure rate of the YEARS algorithm in our pregnant women population was 0/77 (95% confidence interval 0.0-3.9). CONCLUSION In our study, application of the YEARS algorithm would have resulted in safe exclusion of PE in one of five pregnant women without the need for radiation exposure, further supporting the use of the algorithm in this population.
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Affiliation(s)
- Emilie Langlois
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Camille Cusson-Dufour
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Thomas Moumneh
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Emergency Medicine, University Hospital of Angers, University of Angers, MITOVASC, UMR CNRS 6015, UMR INSERM 1083, Angers, France
| | - Antoine Elias
- Médecine vasculaire, Centre Hospitalier de Toulon, Toulon, France
| | - Guy Meyer
- Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- INSERM, UMR S 1140, Paris, France
- F-CRIN INNOVTE, St-Etienne, France
| | - Karine Lacut
- EA3878 GETBO, Université de Brest, Brest, France
| | - Jeannot Schmidt
- Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Céline Chauleur
- Department of Gynecology and Obstetrics, University Hospital, Saint-Etienne, France
| | - Frédéric Glauser
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Grégoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
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30
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Kwan ML, Miglioretti DL, Marlow EC, Aiello Bowles EJ, Weinmann S, Cheng SY, Deosaransingh KA, Chavan P, Moy LM, Bolch WE, Duncan JR, Greenlee RT, Kushi LH, Pole JD, Rahm AK, Stout NK, Smith-Bindman R. Trends in Medical Imaging During Pregnancy in the United States and Ontario, Canada, 1996 to 2016. JAMA Netw Open 2019; 2:e197249. [PMID: 31339541 PMCID: PMC6659354 DOI: 10.1001/jamanetworkopen.2019.7249] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE The use of medical imaging has sharply increased over the last 2 decades. Imaging rates during pregnancy have not been quantified in a large, multisite study setting. OBJECTIVE To evaluate patterns of medical imaging during pregnancy. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was performed at 6 US integrated health care systems and in Ontario, Canada. Participants included pregnant women who gave birth to a live neonate of at least 24 weeks' gestation between January 1, 1996, and December 31, 2016, and who were enrolled in the health care system for the entire pregnancy. EXPOSURES Computed tomography (CT), magnetic resonance imaging, conventional radiography, angiography and fluoroscopy, and nuclear medicine. MAIN OUTCOMES AND MEASURES Imaging rates per pregnancy stratified by country and year of child's birth. RESULTS A total of 3 497 603 pregnancies in 2 211 789 women were included. Overall, 26% of pregnancies were from US sites. Most (92%) were in women aged 20 to 39 years, and 85% resulted in full-term births. Computed tomography imaging rates in the United States increased from 2.0 examinations/1000 pregnancies in 1996 to 11.4/1000 pregnancies in 2007, remained stable through 2010, and decreased to 9.3/1000 pregnancies by 2016, for an overall increase of 3.7-fold. Computed tomography rates in Ontario, Canada, increased more gradually by 2.0-fold, from 2.0/1000 pregnancies in 1996 to 6.2/1000 pregnancies in 2016, which was 33% lower than in the United States. Overall, 5.3% of pregnant women in US sites and 3.6% in Ontario underwent imaging with ionizing radiation, and 0.8% of women at US sites and 0.4% in Ontario underwent CT. Magnetic resonance imaging rates increased steadily from 1.0/1000 pregnancies in 1996 to 11.9/1000 pregnancies in 2016 in the United States and from 0.5/1000 pregnancies in 1996 to 9.8/1000 pregnancies in 2016 in Ontario, surpassing CT rates in 2013 in the United States and in 2007 in Ontario. In the United States, radiography rates doubled from 34.5/1000 pregnancies in 1996 to 72.6/1000 pregnancies in 1999 and then decreased to 47.6/1000 pregnancies in 2016; rates in Ontario slowly increased from 36.2/1000 pregnancies in 1996 to 44.7/1000 pregnancies in 2016. Angiography and fluoroscopy and nuclear medicine use rates were low (5.2/1000 pregnancies), but in most years, higher in Ontario than the United States. Imaging rates were highest for women who were younger than 20 years or aged 40 years or older, gave birth preterm, or were black, Native American, or Hispanic (US data only). Considering advanced imaging only, chest imaging of pregnant women was more likely to use CT in the United States and nuclear medicine imaging in Ontario. CONCLUSIONS AND RELEVANCE The use of CT during pregnancy substantially increased in the United States and Ontario over the past 2 decades. Imaging rates during pregnancy should be monitored to avoid unnecessary exposure of women and fetuses to ionizing radiation.
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Affiliation(s)
- Marilyn L. Kwan
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Diana L. Miglioretti
- Department of Public Health Sciences, University of California, Davis
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Emily C. Marlow
- Department of Public Health Sciences, University of California, Davis
| | - E. J. Aiello Bowles
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Sheila Weinmann
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
- Center for Health Research, Kaiser Permanente Hawaii, Honolulu
| | | | | | - Prachi Chavan
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Lisa M. Moy
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Wesley E. Bolch
- Department of Biomedical Engineering, University of Florida, Gainesville
| | - James R. Duncan
- Interventional Radiology Section, Washington University in St Louis, St Louis, Missouri
| | - Robert T. Greenlee
- Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, Wisconsin
| | - Lawrence H. Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Jason D. Pole
- ICES, Toronto, Ontario, Canada
- Pediatric Oncology Group of Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Alanna K. Rahm
- Center for Health Research, Genomic Medicine Institute, Geisinger, Danville, Pennsylvania
| | - Natasha K. Stout
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - R. Smith-Bindman
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
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Abstract
The American Heart Association (AHA) categorizes pulmonary embolism (PE) into three main categories based on the presence or absence of hemodynamic changes and evidence of right ventricular dysfunction. The AHA characterizes massive PE as occurring in the setting of persistent hypotension, profound bradycardia, or pulselessness; submassive PE as occurring with evidence of right ventricular dysfunction or myocardial necrosis in the absence of hemodynamic changes; and low-risk PE as occurring in the absence of markers of massive and submassive PE. This chapter provides an overview of how to identify and manage patients with submassive and massive pulmonary embolism. Delivery planning considerations are discussed. We also address the management of critically ill obstetric patients with respect to VTE risk. The American Heart Association (AHA) categorizes pulmonary embolism (PE) into three main categories based on the presence or absence of hemodynamic changes and evidence of right ventricular dysfunction. The AHA characterizes massive PE as occurring in the setting of persistent hypotension, profound bradycardia, or pulselessness; submassive PE as occurring with evidence of right ventricular dysfunction or myocardial necrosis in the absence of hemodynamic changes; and low-risk PE as occurring in the absence of markers of massive and submassive PE.1 This chapter provides an overview of how to identify and manage patients with submassive and massive pulmonary embolism. Delivery planning considerations are discussed. We also address the management of critically ill obstetric patients with respect to VTE risk.
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Affiliation(s)
- Roxane C Handal-Orefice
- Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, 622 West 168th Street, New York, NY 10032, United States.
| | - Leslie A Moroz
- Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, 622 West 168th Street, New York, NY 10032, United States
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Righini M, Robert-Ebadi H, Elias A, Sanchez O, Le Moigne E, Schmidt J, Le Gall C, Cornuz J, Aujesky D, Roy PM, Chauleur C, Rutschmann OT, Poletti PA, Le Gal G. Diagnosis of Pulmonary Embolism During Pregnancy: A Multicenter Prospective Management Outcome Study. Ann Intern Med 2018; 169:766-773. [PMID: 30357273 DOI: 10.7326/m18-1670] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Data on the optimal diagnostic management of pregnant women with suspected pulmonary embolism (PE) are limited, and guidelines provide inconsistent recommendations on use of diagnostic tests. OBJECTIVE To prospectively validate a diagnostic strategy in pregnant women with suspected PE. DESIGN Multicenter, multinational, prospective diagnostic management outcome study involving pretest clinical probability assessment, high-sensitivity D-dimer testing, bilateral lower limb compression ultrasonography (CUS), and computed tomography pulmonary angiography (CTPA). (ClinicalTrials.gov: NCT00740454). SETTING 11 centers in France and Switzerland between August 2008 and July 2016. PATIENTS Pregnant women with clinically suspected PE in emergency departments. INTERVENTION Pulmonary embolism was excluded in patients with a low or intermediate pretest clinical probability and a negative D-dimer result. All others underwent lower limb CUS and, if results were negative, CTPA. A ventilation-perfusion (V/Q) scan was done if CTPA results were inconclusive. Pulmonary embolism was excluded if results of the diagnostic work-up were negative, and untreated pregnant women had clinical follow-up at 3 months. MEASUREMENTS The primary outcome was the rate of adjudicated venous thromboembolic events during the 3-month follow-up. RESULTS 441 women were assessed for eligibility, and 395 were included in the study. Among these, PE was diagnosed in 28 (7.1%) (proximal deep venous thrombosis found on ultrasonography [n = 7], positive CTPA result [n = 19], and high-probability V/Q scan [n = 2]) and excluded in 367 (clinical probability and negative D-dimer result [n = 46], negative CTPA result [n = 290], normal or low-probability V/Q scan [n = 17], and other reason [n = 14]). Twenty-two women received extended anticoagulation during follow-up, mainly for previous venous thromboembolic disease. The rate of symptomatic venous thromboembolic events was 0.0% (95% CI, 0.0% to 1.0%) among untreated women after exclusion of PE on the basis of negative results on the diagnostic work-up. LIMITATION There were several protocol deviations, reflecting the difficulty of performing studies in pregnant women with suspected PE. CONCLUSION A diagnostic strategy based on assessment of clinical probability, D-dimer measurement, CUS, and CTPA can safely rule out PE in pregnant women. PRIMARY FUNDING SOURCE Swiss National Foundation for Scientific Research, Groupe d'Etude de la Thrombose de Bretagne Occidentale, and International Society on Thrombosis and Haemostasis.
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Affiliation(s)
- Marc Righini
- Geneva University Hospitals, Geneva, Switzerland (M.R., H.R., O.T.R., P.P.)
| | - Helia Robert-Ebadi
- Geneva University Hospitals, Geneva, Switzerland (M.R., H.R., O.T.R., P.P.)
| | | | - Olivier Sanchez
- Université Paris Descartes, Sorbonne Paris Cité, and Hôpital Européen Georges Pompidou, Paris, France (O.S.)
| | - Emmanuelle Le Moigne
- INSERM UMR S 1140, Paris, France, F-CRIN INNOVTE, Saint-Etienne, France, and Université de Brest, Brest, France (E.L.)
| | - Jeannot Schmidt
- Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France (J.S.)
| | | | - Jacques Cornuz
- Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (J.C.)
| | - Drahomir Aujesky
- Bern University Hospital, University of Bern, Bern, Switzerland (D.A.)
| | | | - Céline Chauleur
- INSERM U1059, University of Lyon, and University Hospital, Saint-Etienne, France (C.C.)
| | | | | | - Grégoire Le Gal
- Université de Brest, Brest, France, and Ottawa Health Research Institute, Ottawa, Ontario, Canada (G.L.)
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Valente AM, Economy KE. Diagnosing Pulmonary Embolism During Pregnancy: Which Test Is Best? Ann Intern Med 2018; 169:810-811. [PMID: 30357267 DOI: 10.7326/m18-2818] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Anne Marie Valente
- Brigham and Women's Hospital and Boston Children's Hospital, Boston, Massachusetts (A.M.V.)
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Abstract
PURPOSE OF REVIEW This manuscript addresses the risks for venous thromboembolism (VTE) during pregnancy and the associated challenges of both diagnosis and treatment. RECENT FINDINGS The obstacles to diagnosis given lack of specificity of typical biomarkers to predict VTE in pregnancy, as well as the unique fetal and bleeding risks introduced by managing massive pulmonary embolism (PE) with thrombolytics or thrombectomy are highlighted. VTE during pregnancy and the postpartum window occurs at a 6-10-fold higher rate compared with age-matched peers and is a major cause of morbidity and mortality. Hypercoagulability persists for 6-8 weeks after delivery with the highest risk of PE being postpartum. The lack of randomized trials in pregnant women leads to variability in practice, which are largely based on expert consensus or extrapolation from non-pregnant cohorts. The standard treatment of VTE in pregnancy is anticoagulation with low molecular weight heparin (LMWH), which like unfractionated heparin does not cross the placenta and is not teratogenic. LMWH is preferred given the negligible risk for heparin-induced thrombocytopenia and osteoporosis, better bioavailability, and a predictive dose response. Depending on the severity of the VTE, additional treatments including thrombolysis, thrombectomy, inferior vena cava filter placement, or venous stenting may be used. Management requires balancing the competing bleeding and thrombotic risks during labor and delivery and factoring the impact of treatment on the fetus. A multidisciplinary team involving hematology, obstetrics, anesthesia, vascular medicine, and cardiology is critical for safe and timely management. The design and execution of prospective, randomized trials to specifically address optimal diagnosis and management are a top priority in obstetric hematology.
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Affiliation(s)
- Annemarie E Fogerty
- Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA.
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Tsuchiya N, Beek EJRV, Ohno Y, Hatabu H, Kauczor HU, Swift A, Vogel-Claussen J, Biederer J, Wild J, Wielpütz MO, Schiebler ML. Magnetic resonance angiography for the primary diagnosis of pulmonary embolism: A review from the international workshop for pulmonary functional imaging. World J Radiol 2018; 10:52-64. [PMID: 29988845 PMCID: PMC6033703 DOI: 10.4329/wjr.v10.i6.52] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 04/25/2018] [Accepted: 05/30/2018] [Indexed: 02/06/2023] Open
Abstract
Pulmonary contrast enhanced magnetic resonance angiography (CE-MRA) is useful for the primary diagnosis of pulmonary embolism (PE). Many sites have chosen not to use CE-MRA as a first line of diagnostic tool for PE because of the speed and higher efficacy of computerized tomographic angiography (CTA). In this review, we discuss the strengths and weaknesses of CE-MRA and the appropriate imaging scenarios for the primary diagnosis of PE derived from our unique multi-institutional experience in this area. The optimal patient for this test has a low to intermediate suspicion for PE based on clinical decision rules. Patients in extremis are not candidates for this test. Younger women (< 35 years of age) and patients with iodinated contrast allergies are best served by using this modality We discuss the history of the use of this test, recent technical innovations, artifacts, direct and indirect findings for PE, ancillary findings, and the effectiveness (patient outcomes) of CE-MRA for the exclusion of PE. Current outcomes data shows that CE-MRA and NM V/Q scans are effective alternative tests to CTA for the primary diagnosis of PE.
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Affiliation(s)
- Nanae Tsuchiya
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Okinawa 903-0215, Japan
- Department of Radiology, University of Wisconsin-Madison, Madison, WI 53792, United States
| | - Edwin JR van Beek
- Edinburgh Imaging, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, United Kingdom
| | - Yoshiharu Ohno
- Division of Functional and Diagnostic Imaging Research, Department of Radiology, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Hiroto Hatabu
- Department of Radiology, Brigham and Women’s Hospital, Boston, MA 02115, United States
| | - Hans-Ulrich Kauczor
- Department of Diagnostic and Interventional Radiology, University Hospital of Heidelberg, Heidelberg 69120, Germany
| | - Andrew Swift
- Department of Radiology, Royal Hallamshire Hospital, University of Sheffield, Sheffield S10 2JF, United Kingdom
| | - Jens Vogel-Claussen
- Department of Radiology, Carl-Neuberg Strasse 1, Hannover-Gr-Buchholz 30625, Germany
| | - Jürgen Biederer
- Radiology Darmstadt, Gross-Gerau County Hospital, Gross-Gerau 64521, Germany
| | - James Wild
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2JF, United Kingdom
| | - Mark O Wielpütz
- Department of Diagnostic and Interventional Radiology, University Hospital of Heidelberg, Heidelberg 69120, Germany
| | - Mark L Schiebler
- Department of Radiology, University of Wisconsin-Madison, Madison, WI 53792, United States
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36
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Abstract
Venous thromboembolism is a leading cause of maternal death. Because of the low absolute frequency of events, however, outcome-based clinical data are limited. Consequently, clinicians must additionally rely both on published guidelines and on extrapolation of data from studies focused on nonpregnant individuals. The diagnosis and treatment of deep vein thrombosis, pulmonary embolism, and cerebral vein and dural sinus thrombosis are complicated by pregnancy, and often require modifications to standard diagnostic and treatment algorithms outside of pregnancy. Treatment of VTE in pregnant women is in particular need of future research.
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Malinowski AK. Diagnostic approach to pulmonary embolism in pregnancy: are the winds of change upon us or is it déjà vu all over again? Br J Haematol 2018; 180:625-627. [PMID: 29363743 DOI: 10.1111/bjh.15100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Ann Kinga Malinowski
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada.,Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada
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Acute respiratory diseases in pregnancy. GINECOLOGIA.RO 2018. [DOI: 10.26416/gine.22.4.2018.2139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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