1
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Gillespie CD, Yates A, Hughes M, Ewins K, McMahon G, Hynes J, Murphy MC, Galligan M, Vencken S, Alih E, Varden J, Donnelly J, Bolster F, Rowan M, Foley S, NíAinle F, MacMahon PJ. Validating the safety of low-dose CTPA in pregnancy: results from the OPTICA (Optimised CT Pulmonary Angiography in Pregnancy) Study. Eur Radiol 2024; 34:4864-4873. [PMID: 38296849 DOI: 10.1007/s00330-024-10593-y] [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: 09/22/2023] [Revised: 12/23/2023] [Accepted: 12/27/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND Pulmonary embolism (PE) is a leading cause of pregnancy-related mortality. CT pulmonary angiogram (CTPA) is the first-line advanced imaging modality for suspected PE in pregnancy at institutes offering low-dose techniques; however, a protocol balancing safety with low dose remains undefined. The wide range of CTPA doses reported in pregnancy suggests a lack of confidence in implementing low-dose techniques in this group. PURPOSE To define and validate the safety, radiation dose and image quality of a low-dose CTPA protocol optimised for pregnancy. MATERIALS AND METHODS The OPTICA study is a prospective observational study. Pregnant study participants with suspected PE underwent the same CTPA protocol between May 2018 and February 2022. The primary outcome, CTPA safety, was judged by the reference standard; the 3-month incidence of venous thromboembolism (VTE) in study participants with a negative index CTPA. Secondary outcomes defined radiation dose and image quality. Absorbed breast, maternal effective and fetal doses were estimated by Monte-Carlo simulation on gestation-matched phantoms. Image quality was assessed by signal-to-noise and contrast-to-noise ratios and a Likert score for pulmonary arterial enhancement. RESULTS A total of 116 CTPAs were performed in 113 pregnant women of which 16 CTPAs were excluded. PE was diagnosed on 1 CTPA and out-ruled in 99. The incidence of recurrent symptomatic VTE was 0.0% (one-sided 95% CI, 2.66%) at follow-up. The mean absorbed breast dose was 2.9 ± 2.1mGy, uterine/fetal dose was 0.1 ± 0.2mGy and maternal effective dose was 1.4 ± 0.9mSv. Signal-to-noise ratio (SNR) was 11.9 ± 3.7. Contrast-to-noise ratio (CNR) was 10.4 ± 3.5. CONCLUSION The OPTICA CTPA protocol safely excluded PE in pregnant women across all trimesters, with low fetal and maternal radiation. CLINICAL RELEVANCE OPTICA (Optimised CT Pulmonary Angiography in Pregnancy) is the first prospective study to define the achievable radiation dose, image-quality and safety of a low-dose CT pulmonary angiogram protocol optimised for pregnancy (NCT04179487). It provides the current benchmark for safe and achievable CT pulmonary angiogram doses in the pregnant population. KEY POINTS • Despite the increased use of CT pulmonary angiogram in pregnancy, an optimised low-dose protocol has not been defined and reported doses in pregnancy continue to vary widely. • The OPTICA (Optimised CT Pulmonary Angiography in Pregnancy) study prospectively defines the achievable dose, image quality and safety of a low-dose CT pulmonary angiogram protocol using widely available technology. • OPTICA provides a benchmark for safe and achievable CT pulmonary angiogram doses in the pregnant population.
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Affiliation(s)
- Ciara D Gillespie
- Department of Radiology, Mater Misericordiae University Hospital, Whitty Building, North Circular Road, Dublin 7, Dublin, D07 R2WY, Ireland.
| | - Andrew Yates
- Department of Radiology, Mater Misericordiae University Hospital, Whitty Building, North Circular Road, Dublin 7, Dublin, D07 R2WY, Ireland
| | - Mark Hughes
- Department of Radiology, Mater Misericordiae University Hospital, Whitty Building, North Circular Road, Dublin 7, Dublin, D07 R2WY, Ireland
| | - Karl Ewins
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, D07 R2WY, Ireland
| | - Gabriella McMahon
- Department of Obstetrics, Rotunda Hospital, Dublin, D01 P5W9, Ireland
| | - John Hynes
- Department of Radiology, Mater Misericordiae University Hospital, Whitty Building, North Circular Road, Dublin 7, Dublin, D07 R2WY, Ireland
| | - Mark C Murphy
- Department of Radiology, Mater Misericordiae University Hospital, Whitty Building, North Circular Road, Dublin 7, Dublin, D07 R2WY, Ireland
| | - Marie Galligan
- Clinical Research Centre, School of Medicine, University College Dublin, Dublin, D04 V1W8, Ireland
| | - Sebastian Vencken
- Clinical Research Centre, School of Medicine, University College Dublin, Dublin, D04 V1W8, Ireland
| | - Ekele Alih
- Clinical Research Centre, School of Medicine, University College Dublin, Dublin, D04 V1W8, Ireland
| | - John Varden
- Department of Radiology, Mater Misericordiae University Hospital, Whitty Building, North Circular Road, Dublin 7, Dublin, D07 R2WY, Ireland
| | - Jennifer Donnelly
- Department of Obstetrics, Rotunda Hospital, Dublin, D01 P5W9, Ireland
- School of Medicine, University College Dublin, Dublin, D04 V1W8, Ireland
| | - Ferdia Bolster
- Department of Radiology, Mater Misericordiae University Hospital, Whitty Building, North Circular Road, Dublin 7, Dublin, D07 R2WY, Ireland
- School of Medicine, University College Dublin, Dublin, D04 V1W8, Ireland
| | - Michael Rowan
- Department of Medical Physics, St James Hospital, Dublin, D08 NHY1, Ireland
| | - Shane Foley
- Radiography & Diagnostic Imaging, School of Medicine, University College Dublin, Dublin, D04 V1W8, Ireland
| | - Fionnuala NíAinle
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, D07 R2WY, Ireland
- School of Medicine, University College Dublin, Dublin, D04 V1W8, Ireland
| | - Peter J MacMahon
- Department of Radiology, Mater Misericordiae University Hospital, Whitty Building, North Circular Road, Dublin 7, Dublin, D07 R2WY, Ireland
- School of Medicine, University College Dublin, Dublin, D04 V1W8, Ireland
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2
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Kilkenny K, Frishman W. Venous Thromboembolism in Pregnancy: A Review of Diagnosis, Management, and Prevention. Cardiol Rev 2024:00045415-990000000-00306. [PMID: 39051770 DOI: 10.1097/crd.0000000000000756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism, is a leading cause of maternal morbidity and mortality worldwide. Physiological changes that occur in a normal pregnancy increase the risk for VTE by 4-5-fold in the antepartum period and 30-60-fold in the immediate postpartum period. Compressive ultrasonography is the diagnostic test of choice for deep vein thrombosis. Both ventilation/perfusion scanning and computed tomography pulmonary angiography can reliably diagnose pulmonary embolism. Anticoagulation for a minimum of 3 months, typically with low molecular weight heparin, is the treatment of choice for pregnancy-associated VTE (PA-VTE). Despite the significant societal burden and potentially devastating consequences, there is a paucity of data surrounding the prevention of PA-VTE, resulting in major variations between international guidelines. This review will summarize the current recommendations for diagnosis, management, and prevention of PA-VTE.
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Affiliation(s)
- Katherine Kilkenny
- From the Department of Medicine, New York Presbyterian-Weill Cornell Medicine, New York, NY
- Department of Medicine, New York Medical College, School of Medicine, Valhalla, NY
| | - William Frishman
- Department of Medicine, New York Medical College, School of Medicine, Valhalla, NY
- Department of Medicine, Westchester Medical Center, Valhalla, NY
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Martens ESL, Huisman MV, van Mens TE, Klok FA. The History of Diagnosing Venous Thromboembolism. Semin Thromb Hemost 2024; 50:739-750. [PMID: 38373722 DOI: 10.1055/s-0044-1779484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
An accurate and prompt diagnosis of deep vein thrombosis and/or pulmonary embolism is important to prevent serious complications and mortality. Because the clinical presentation of venous thromboembolism (VTE) is often nonspecific, objective testing by means of radiological imaging is required to confirm the diagnosis. Historically, a diagnosis of VTE involved invasive imaging techniques like contrast venography or conventional pulmonary angiography. Technological developments toward more accurate and less invasive diagnostics have driven the implementation of a variety of newer technologies over the past decades, as well as the derivation and validation of clinical decision rules (CDRs) that can be used to rule out VTE in combination with D-dimer blood tests. In this narrative review, we provide a historical overview of the most notable developments in the imaging techniques and CDRs for VTE diagnosis.
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Affiliation(s)
- Emily S L Martens
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V Huisman
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Thijs E van Mens
- 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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4
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Thonon H, Van Nieuwenhove M, Thachil J, Lippi G, Hardy M, Mullier F. Hemostasis Testing in the Emergency Department: A Narrative Review. Semin Thromb Hemost 2024. [PMID: 38897223 DOI: 10.1055/s-0044-1787661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Routine laboratory screening is typically performed at initial evaluation of the vast majority of presentations to the emergency department (ED). These laboratory results are crucial to the diagnostic process, as they may influence up to 70% of clinical decisions. However, despite the usefulness of biological assessments, many tests performed are inappropriate or of doubtful clinical relevance. This overutilization rate of laboratory testing in hospitals, which represents a significant medical-economic burden, ranges from 20 to 67%, with coagulation tests at the top of the list. While reviews frequently focus on nonintensive care units, there are few published assessments of emergency-specific interventions or guidelines/guidance to date. The aim of this review is to highlight current recommendations for hemostasis evaluation in the emergency setting with a specific analysis of common situations leading to ED admissions, such as suspected venous thrombosis or severe bleeding. We revisit the evidence related to the assessment of patient's hemostatic capacity based on comprehensive history taking and physical examination as well as best practice recommendations for blood sample collection to ensure the reliability of results. This review also includes an examination of various currently available point of care tests and a comprehensive discussion on indications, limitations, and interpretation of these tests.
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Affiliation(s)
- Henri Thonon
- Emergency Department, Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Yvoir, Belgium
| | | | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Manchester, United Kingdom
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Michael Hardy
- Department of Anesthesiology, Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Yvoir, Belgium
| | - François Mullier
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Hematology Laboratory, Yvoir, Belgium
- Institut de Recherche Expérimentale et Clinique (IREC), Pôle Mont, Université catholique de Louvain (UCLouvain), Yvoir, Belgium
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5
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Li R, Chen S, Xia J, Zhou H, Shen Q, Li Q, Dong Q. Predictive modeling of deep vein thrombosis risk in hospitalized patients: A Q-learning enhanced feature selection model. Comput Biol Med 2024; 175:108447. [PMID: 38691912 DOI: 10.1016/j.compbiomed.2024.108447] [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: 12/13/2023] [Revised: 03/23/2024] [Accepted: 04/07/2024] [Indexed: 05/03/2024]
Abstract
Deep vein thrombosis (DVT) represents a critical health concern due to its potential to lead to pulmonary embolism, a life-threatening complication. Early identification and prediction of DVT are crucial to prevent thromboembolic events and implement timely prophylactic measures in high-risk individuals. This study aims to examine the risk determinants associated with acute lower extremity DVT in hospitalized individuals. Additionally, it introduces an innovative approach by integrating Q-learning augmented colony predation search ant colony optimizer (QL-CPSACO) into the analysis. This algorithm, then combined with support vector machines (SVM), forms a bQL-CPSACO-SVM feature selection model dedicated to crafting a clinical risk prognostication model for DVT. The effectiveness of the proposed algorithm's optimization and the model's accuracy are assessed through experiments utilizing the CEC 2017 benchmark functions and predictive analyses on the DVT dataset. The experimental results reveal that the proposed model achieves an outstanding accuracy of 95.90% in predicting DVT. Key parameters such as D-dimer, normal plasma prothrombin time, prothrombin percentage activity, age, previously documented DVT, leukocyte count, and thrombocyte count demonstrate significant value in the prognostication of DVT. The proposed method provides a basis for risk assessment at the time of patient admission and offers substantial guidance to physicians in making therapeutic decisions.
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Affiliation(s)
- Rizeng Li
- Department of General Surgery, The Second Affiliated Hospital of Shanghai University (Wenzhou Central Hospital), Wenzhou, Zhejiang, 325000, China.
| | - Sunmeng Chen
- Department of General Surgery, The Second Affiliated Hospital of Shanghai University (Wenzhou Central Hospital), Wenzhou, Zhejiang, 325000, China.
| | - Jianfu Xia
- Department of General Surgery, The Second Affiliated Hospital of Shanghai University (Wenzhou Central Hospital), Wenzhou, Zhejiang, 325000, China.
| | - Hong Zhou
- Department of General Surgery, The Second Affiliated Hospital of Shanghai University (Wenzhou Central Hospital), Wenzhou, Zhejiang, 325000, China.
| | - Qingzheng Shen
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325000, China.
| | - Qiang Li
- School of Computer Science and Technology, Beijing Institute of Technology, Beijing, China.
| | - Qiantong Dong
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325000, China.
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6
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Ehrlich R, Lowe S. An audit of CTPA and V/Q scan for investigation of pulmonary embolism in pregnancy. Obstet Med 2024; 17:92-95. [PMID: 38784183 PMCID: PMC11110744 DOI: 10.1177/1753495x231197563] [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: 05/15/2023] [Accepted: 08/04/2023] [Indexed: 05/25/2024] Open
Abstract
Background Pulmonary embolism (PE) can be fatal yet difficult to diagnose in pregnancy. Computed tomography pulmonary angiogram (CTPA) or ventilation/perfusion (V/Q) scans are often conducted, potentially leading to low positive scan rates. Methods Retrospective data analysis was conducted for pregnant women and non-pregnant age-matched control who underwent CTPA and/or V/Q scan for investigation of PE. The main outcomes were the positive and non-diagnostic imaging rates. Results In total, 440 women underwent V/Q or CTPA scans, 86 of whom were pregnant (19.5%). The positive scan rate was 3.5% and 8.8% in the pregnant and non-pregnant groups, respectively (p = 0.1). The non-diagnostic scan rate was similar between pregnant and non-pregnant groups (13.9% vs 9.9%, p = 0.3). Within the pregnant group, there were more non-diagnostic CTPAs than V/Q scans (p = 0.005). Conclusion Our study confirms a low positive imaging rate and a relatively high non-diagnostic CTPA rate in pregnancy. Newer strategies are needed to reduce the number of negative imaging studies conducted.
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Affiliation(s)
- Romy Ehrlich
- Romy Ehrlich, Royal Hospital for Women, University of New South Wales, Barker Street, Randwick, NSW 2031, Australia.
| | - Sandra Lowe
- Royal Hospital for Women, University of New South Wales, Australia
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7
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Revel MP, Chassagnon G, Sanchez O, Ferretti G, Millet I, Rocher L, Maitre S, Lederlin M, Ducou-le-Pointe H, Rousset P, Bennani S, Zins M, Bruneau B, Tissot V, Alison M, Canniff E, Siauve N, Vandeventer S, Le Blanche AF, Planquette B, Tsatsaris V, Coste J. CT venography for the diagnosis of postpartum venous thromboembolism: a prospective multi-center cohort study. Eur Radiol 2024:10.1007/s00330-024-10791-8. [PMID: 38782788 DOI: 10.1007/s00330-024-10791-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/22/2024] [Accepted: 02/26/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVES To assess the role of CT venography (CTV) in the diagnosis of venous thromboembolism (VTE) during the postpartum period. MATERIALS AND METHODS This multicenter prospective cohort study was conducted between April 2016 and April 2020 in 14 university hospitals. All women referred for CT pulmonary angiography (CTPA) for suspected pulmonary embolism (PE) within the first 6 weeks postpartum were eligible. All CTPAs were performed on multidetector CT machines with the usual parameters and followed by CTV of the abdomen, pelvis, and proximal lower limbs. On-site reports were compared to expert consensus reading, and the added value of CTV was assessed for both. RESULTS The final study population consisted of 123 women. On-site CTPA reports mentioned PE in seven women (7/123, 5.7%), all confirmed following expert consensus reading, three involving proximal pulmonary arteries and four limited to distal arteries. Positive CTV was reported on-site in nine women, five of whom had negative and two indeterminate CTPAs, bringing the VTE detection rate to 11.4% (14/123) (95%CI: 6.4-18.4, p = 0.03). Expert consensus reading confirmed all positive on-site CTV results, but detected a periuterine vein thrombosis in an additional woman who had a negative CTPA, increasing the VTE detection rate to 12.2% (15/123) (95%CI: 7.0-19.3, p = 0.008). Follow-up at 3 months revealed no adverse events in this woman, who was left untreated. Median Dose-Length-Product was 117 mGy.cm for CTPA and 675 mGy.cm for CTPA + CTV. CONCLUSION Performing CTV in women suspected of postpartum PE doubles the detection of venous thromboembolism, at the cost of increased radiation exposure. CLINICAL RELEVANCE STATEMENT CTV can help in the decision-making process concerning curative anticoagulation in women with suspected postpartum PE, particularly those whose CTPA results are indeterminate or whose PE is limited to the subsegmental level. KEY POINTS Postpartum women are at risk of pulmonary embolism, and CT pulmonary angiography can give equivocal results. CT venography (CTV) positivity increased the venous thromboembolism detection rate from 5.7 to 11.4%. CTV may help clinical decision-making, especially in women with indeterminate CTPA results or subsegmental emboli.
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Affiliation(s)
- Marie-Pierre Revel
- Université Paris Cité, Paris, France.
- APHP, Hôpital Cochin, Service de Radiologie, Paris, France.
| | - Guillaume Chassagnon
- Université Paris Cité, Paris, France
- APHP, Hôpital Cochin, Service de Radiologie, Paris, France
| | - Olivier Sanchez
- Université Paris Cité, Paris, France
- APHP, Hôpital Européen Georges Pompidou, Service de pneumologie et de soins intensifs, Paris, France
| | - Gilbert Ferretti
- Université Grenoble Alpes, Grenoble, France
- CHU Grenoble Alpes, Service de Radiologie, Grenoble, France
| | - Ingrid Millet
- IDESP, Université de Montpellier, Montpellier, France
- CHU Lapeyronie, Service de Radiologie, Montpellier, France
| | - Laurence Rocher
- Université Paris-Saclay, Orsay, France
- APHP, Hôpital Antoine Béclère, Service de Radiologie, Clamart, France
| | - Sophie Maitre
- APHP, Hôpital Antoine Béclère, Service de Radiologie, Clamart, France
| | - Mathieu Lederlin
- Université de Rennes 1, Rennes, France
- Hôpital Pontchaillou, Service de Radiologie, Rennes, France
| | - Hubert Ducou-le-Pointe
- Sorbonne Université, Paris, France
- APHP, Hôpital Armand Trousseau, Service de Radiologie, Paris, France
| | - Pascal Rousset
- Université Claude Bernard Lyon 1, Villeurbanne, France
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service de Radiologie, Pierre Bénite, France
| | | | - Marc Zins
- Hôpital Saint Joseph, Service de Radiologie, Paris, France
| | | | - Valentin Tissot
- Centre Hospitalier Universitaire de Brest, Service de Radiologie, Brest, France
| | - Marianne Alison
- Université Paris Cité, Paris, France
- APHP, Hôpital Robert Debré, Service de Radiologie, Paris, France
| | - Emma Canniff
- Université Paris Cité, Paris, France
- APHP, Hôpital Cochin, Service de Radiologie, Paris, France
| | - Nathalie Siauve
- Université Paris Cité, Paris, France
- APHP, Hôpital Louis Mourier, Service de Radiologie, Colombes, France
| | - Stephanie Vandeventer
- Université Paris Cité, Paris, France
- APHP, Hôpital Necker, Service de Radiologie, Paris, France
| | - Alain F Le Blanche
- Université Paris-Saclay, Orsay, France
- Centre hospitalier Nord-Ouest Val d'Oise, Site de Pontoise, Service de Radiologie, Pontoise, France
| | - Benjamin Planquette
- Université Paris Cité, Paris, France
- APHP, Hôpital Européen Georges Pompidou, Service de pneumologie et de soins intensifs, Paris, France
| | - Vassilis Tsatsaris
- Université Paris Cité, Paris, France
- APHP, Hôpital Cochin, Maternité Port-Royal, FHU PREMA, Paris, France
| | - Joël Coste
- Université Paris Cité, Paris, France
- APHP, Hôpital Cochin, Service d'Epidémiologie et de Biostatistiques, Paris, France
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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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Frank AK, Samuelson Bannow B. Venous thromboembolism in pregnancy and postpartum: an illustrated review. Res Pract Thromb Haemost 2024; 8:102446. [PMID: 39045339 PMCID: PMC11263788 DOI: 10.1016/j.rpth.2024.102446] [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: 02/07/2024] [Revised: 05/10/2024] [Accepted: 05/14/2024] [Indexed: 07/25/2024] Open
Abstract
The topic of this review is venous thromboembolism (VTE) during pregnancy and postpartum. The following topics will be addressed: epidemiology and pathophysiology of VTE in pregnancy and postpartum, diagnostic considerations for VTE in pregnancy, indications for prophylactic and therapeutic anticoagulation in pregnancy and postpartum, choice of anticoagulation in pregnancy and breastfeeding, anticoagulation management during labor and delivery, and anticoagulation considerations for assisted reproductive technology.
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Affiliation(s)
- Annabel K. Frank
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, California, USA
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10
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Birrenkott DA, Kabrhel C, Dudzinski DM. Intermediate-Risk and High-Risk Pulmonary Embolism: Recognition and Management: Cardiology Clinics: Cardiac Emergencies. Cardiol Clin 2024; 42:215-235. [PMID: 38631791 DOI: 10.1016/j.ccl.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Pulmonary embolism (PE) is the third most common cause of cardiovascular death. Every specialty of medical practitioner will encounter PE in their patients, and should be prepared to employ contemporary strategies for diagnosis and initial risk-stratification. Treatment of PE is based on risk-stratification, with anticoagulation for all patients, and advanced modalities including systemic thrombolysis, catheter-directed therapies, and mechanical circulatory supports utilized in a manner paralleling PE severity and clinical context.
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Affiliation(s)
- Drew A Birrenkott
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - David M Dudzinski
- Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiac Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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11
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Fitzsimmons J, Hart L, Oliver E, Mulla W. Diagnosis of Pulmonary Embolism in Pregnancy. Am J Perinatol 2024; 41:e2307-e2312. [PMID: 37336499 DOI: 10.1055/a-2112-8049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
Pulmonary embolism (PE) is a significant cause of obstetric morbidity and mortality. However, overdiagnosis related to excessive use of diagnostic testing is also associated with long-term major health issues, including impact on future pregnancies and subsequent health care. Accurate diagnosis of PE depends on the knowledge of prevalence of PE in the pregnant population, the a priori probability of a PE based on specific findings in a given patient, and understanding of the accuracy of computed tomography pulmonary angiography (CTPA), the dominant diagnostic modality employed for this diagnosis. Venous thromboembolism is widely considered to be more common in pregnancy. However, this term includes both deep venous thrombosis as well as PE. While the former appears to be more common, published data on the prevalence of PE in pregnancy show little or no increase relative to the general population. Given the published data on the sensitivity and specificity of CTPA, a positive reading is more likely to be a false positive unless the probability of a PE in a given patient is at least 5% (a 200-fold increase from baseline). Doubling the probability to 10% (a 400-fold increase) only improves the positive predictive value to approximately 67%. Strategies to refine the a priori probability of a PE in a given patient are detailed, including scoring systems and D-dimer measurements. A careful history and physical examination and thoughtful development of a differential diagnosis are key elements of clinical practice and should include both the likelihood of each possible diagnosis and the accuracy of diagnostic modalities. This approach should precede the application of a given algorithm. Such a structured approach can decrease utilization and limit false positive diagnoses without increasing morbidity or mortality. KEY POINTS: · Incidence of PE is lower than assumed.. · Incidence is critical for assessing predictive value of a test.. · Computed tomography angiography is likely overused in pregnancy.. · Clinical scoring and D-dimer have a role in PE diagnosis..
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Affiliation(s)
- Jack Fitzsimmons
- Department of Obstetrics, Gynecology and Reproductive Sciences, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Laura Hart
- Department of Obstetrics, Gynecology and Reproductive Sciences, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Emily Oliver
- Department of Obstetrics, Gynecology and Reproductive Sciences, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Wadia Mulla
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
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12
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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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13
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van de Bovenkamp AA, Kalkman DN, Beijk MAM, van de Veerdonk MC. Recurrent angina and cardiac ischaemia as a presentation of pheochromocytoma: a case report. Eur Heart J Case Rep 2024; 8:ytae153. [PMID: 38645675 PMCID: PMC11032188 DOI: 10.1093/ehjcr/ytae153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 03/09/2024] [Accepted: 03/19/2024] [Indexed: 04/23/2024]
Abstract
Background We present a case of a pregnant patient with recurrent angina, in which her symptoms were initially attributed to coronary artery spasm. However, during follow-up, she was diagnosed as having pheochromocytoma, a rare neuroendocrine tumour. Case summary The 35-year-old patient was admitted to the hospital because of chest pain and elevated cardiac troponins after the use of MDMA. Physical examination, electrocardiogram, echocardiography, coronary angiogram, and cardiac MRI were normal. Symptoms were attributed to coronary spasm, and a calcium antagonist was started. Ten months later, when 36 weeks pregnant, her symptoms returned. One week later, the patient was readmitted to the hospital with signs of acute left ventricular (LV) failure, highly elevated troponins, and severe global LV dysfunction. Urgent section caesarean was performed due to maternal morbidity and foetal tachycardia. During section, flushes and marked variability in blood pressure were noted. Laboratory metanephrines testing was performed. LV function recovered within 3 days without any therapeutic intervention. However, chest pain reoccurred, now accompanied with headaches, malignant hypertension, and accelerated idiopathic ventricular rhythms. (Nor)metanephrines tests were positive. A solid lesion in the right adrenal on CT scan confirmed the diagnosis of pheochromocytoma. Fluid repletion and alpha-blocker therapy were started. Due to persistent symptoms, urgent laparoscopic adrenalectomy was performed. Hereafter, the patient remained without symptoms. Discussion A pheochromocytoma may present with recurrent angina and can result in a catecholamine-induced cardiomyopathy. It is important to timely recognize this diagnosis in order to minimize morbidity and mortality.
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Affiliation(s)
- Arno A van de Bovenkamp
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Deborah N Kalkman
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Marcel A M Beijk
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Mariëlle C van de Veerdonk
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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14
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Lee SH, Hong JH, Kim C. Atypical presentation of DeBakey type I aortic dissection mimicking pulmonary embolism in a pregnant patient: a case report. JOURNAL OF YEUNGNAM MEDICAL SCIENCE 2024; 41:128-133. [PMID: 38311803 DOI: 10.12701/jyms.2023.01319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/28/2023] [Indexed: 02/06/2024]
Abstract
Aortic dissection in pregnant patients results in an inpatient mortality rate of 8.6%. Owing to the pronounced mortality rate and speed at which aortic dissections progress, efficient early detection methods are crucial. Here, we highlight the importance of early chest computed tomography (CT) for differentiating aortic dissection from pulmonary embolism in pregnant patients with dyspnea. We present the unique case of a 38-year-old pregnant woman with elevated D-dimer and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels, initially suspected of having a pulmonary embolism. Initial transthoracic echocardiography did not indicate aortic dissection. Surprisingly, after an emergency cesarean section, a chest CT scan revealed a DeBakey type I aortic dissection, indicating a diagnostic error. Our findings emphasize the need for early chest CT in pregnant patients with dyspnea and elevated D-dimer and NT-proBNP levels. This case report highlights the critical importance of considering both aortic dissection and pulmonary embolism in the differential diagnosis of such cases, which will inform future clinical practice.
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Affiliation(s)
- Sou Hyun Lee
- Department of Anesthesiology and Pain Medicine, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Ji Hee Hong
- Department of Anesthesiology and Pain Medicine, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Chaeeun Kim
- Department of Anesthesiology and Pain Medicine, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
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15
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Goyal SK, Wang JJ, McCandlish JA, Cronin PP, Barish M, Sanelli PC, Cohen SL. Ten-Year Trend in Advanced Imaging Utilization for Suspected Pulmonary Embolism in Pregnancy. J Am Coll Radiol 2024; 21:549-557. [PMID: 37775066 DOI: 10.1016/j.jacr.2023.08.045] [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: 02/17/2023] [Revised: 08/18/2023] [Accepted: 08/25/2023] [Indexed: 10/01/2023]
Abstract
PURPOSE Advanced imaging is essential to diagnose pulmonary embolism (PE) in pregnancy, but there are associated maternal and fetal radiation risks. The purpose of this study was to evaluate the 10-year trend in advanced imaging utilization for the evaluation of suspected PE in pregnancy. METHODS The authors evaluated pregnant women with advanced imaging using CT pulmonary angiography (CTPA) or lung scintigraphy (LS) for evaluation of suspected PE presenting to two tertiary hospitals from 2007 to 2016. The rate of imaging was evaluated relative to positive PE rate and local pregnancy rate. positive PE was defined as a new acute PE finding on any advanced imaging within 3 days of first advanced imaging test. Local pregnancy rates were defined per 1,000 pregnancies in the county serviced by both hospitals. Chi-square testing was used to evaluate statistical significance (P < .05) in the utilization trend of advanced imaging and relative to local pregnancy rates and evaluations positive for PE. RESULTS A total of 707 pregnant patients were identified, of whom 92.5% (n = 654) underwent CTPA and 7.5% (n = 53) underwent LS. Regression analysis showed an average increase of 5.2 advanced imaging studies per year (P < .001), with 61 and 105 studies performed in 2007 and 2016, respectively. Additionally, there was an average increase of 0.08 (P < .001) advanced imaging studies per 1,000 local pregnancies per year, doubling from 0.7 in 2007 to 1.4 in 2016 (P < .001). Finally, there was a decrease of 0.004 (P = .009) in advanced imaging positive for PE, from 3% (2 of 61) in 2007 to 0% (0 of 100) in 2016. CONCLUSIONS Advanced imaging utilization increased by 72% over the 10-year window, driven by higher use of CTPA. Although the detection rate of PE on advanced imaging has decreased, the utilization rate among pregnant patients doubled during this period. These results highlight the need to consider the radiation risks and costs of advanced imaging in specific patient populations.
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Affiliation(s)
- Sameer K Goyal
- Department of Radiology, Northwell Health, Manhasset, New York
| | - Jason J Wang
- The Feinstein Institutes for Medical Research, Manhasset, New York
| | | | - Paul P Cronin
- Department of Radiology and Imaging Science, Emory University Hospital, Atlanta, Georgia
| | - Matthew Barish
- Department of Radiology, Northwell Health, Manhasset, New York
| | - Pina C Sanelli
- Vice Chairman of Research and Executive Director, Imaging Clinical Effectiveness and Outcomes Research, Manhasset, New York
| | - Stuart L Cohen
- Department of Radiology, Imaging Clinical Effectiveness and Outcomes Research, Manhasset, New York.
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16
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Cohen SL, Feizullayeva C, Wang JJ, Chan N, McCandlish JA, Cronin PP, Barish MA, O'Connell W, Sanelli PC. Maternal and Fetal Radiation-Induced Cancer Risk From Computed Tomography Pulmonary Angiography During Pregnancy: A Retrospective Cohort Study Across a Multihospital Integrated Health Care Network. J Comput Assist Tomogr 2024; 48:257-262. [PMID: 38271533 DOI: 10.1097/rct.0000000000001545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
OBJECTIVE Computed tomography pulmonary angiogram (CTPA) is important to evaluate suspected pulmonary embolism in pregnancy but has maternal/fetal radiation risks. The objective of this study was to estimate maternal and fetal radiation-induced cancer risk from CTPA during pregnancy. METHODS Simulation modeling via the National Cancer Institute's Radiation Risk Assessment Tool was used to estimate excess cancer risks from 17 organ doses from CTPA during pregnancy, with doses determined by a radiation dose indexing monitoring system. Organ doses were obtained from a radiation dose indexing monitoring system. Maternal and fetal cancer risks per 100,000 were calculated for male and female fetuses and several maternal ages. RESULTS The 534 CTPA examinations had top 3 maternal organ doses to the breast, lung, and stomach of 17.34, 15.53, and 9.43 mSv, respectively, with a mean uterine dose of 0.21 mSv. The total maternal excess risks of developing cancer per 100,000 were 181, 151, 121, 107, 94.5, 84, and 74.4, respectively, for a 20-, 25-, 30-, 35-, 40-, 45-, and 50-year-old woman undergoing CTPA, compared with baseline cancer risks of 41,408 for 20-year-old patients. The total fetal excess risks of developing cancer per 100,000 were 12.3 and 7.3 for female and male fetuses, respectively, when compared with baseline cancer risks of 41,227 and 48,291. DISCUSSION Excess risk of developing cancer from CTPA was small relative to baseline cancer risk for pregnant patients and fetuses, decreased for pregnant patients with increasing maternal age, and was greater for female fetuses than male fetuses.
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Affiliation(s)
| | | | | | - Nicholas Chan
- Department of Medicine, Cleveland Clinic, Cleveland, OH
| | | | - Paul P Cronin
- Department of Radiology and Imaging Science, Emory University Hospital, Atlanta, GA
| | - Matthew A Barish
- Department of Diagnostic Radiology, North Shore University Hospital/Northwell Health, Manhasset, NY
| | - William O'Connell
- Department of Diagnostic Radiology, North Shore University Hospital/Northwell Health, Manhasset, NY
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17
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Lutfi A, O'Rourke E, Crowley M, Craig E, Worrall A, Kevane B, O'Shaughnessy F, Donnelly J, Cleary B, Áinle FN. VTE risk assessment, prevention and diagnosis in pregnancy. Thromb Res 2024; 235:164-174. [PMID: 38350183 DOI: 10.1016/j.thromres.2024.01.025] [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: 09/24/2023] [Revised: 12/18/2023] [Accepted: 01/02/2024] [Indexed: 02/15/2024]
Abstract
Venous thromboembolism (VTE) is still reported as the leading cause of direct maternal death in pregnancy in serial international reports in developed countries. VTE risk is higher during pregnancy but is further increased by additional well-characterized risk factors. International guidelines recommend that formal VTE risk assessment should be conducted at least in early pregnancy, at delivery and when risk factors change. High quality data supporting optimal VTE prevention strategies are lacking, outside the setting of prevention of VTE recurrence. Moreover, recent high-quality studies have provided much-needed data on diagnostic strategies for pulmonary embolism (PE) in pregnancy. In this review, we summarize knowledge gaps and recently published data in the prevention and diagnosis of VTE in pregnancy. Moreover, we describe ongoing high-quality randomised trials and prospective clinical management studies in this area. High quality clinical studies and trials in pregnancy can be done and must be prioritised, through international network efforts and national funding advocacy. Ultimately, translation of study results to impact upon guidelines and policy will deliver better care to and will protect the lives and health of pregnant people and those contemplating pregnancy throughout the world.
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Affiliation(s)
- Ahmed Lutfi
- Cork University Maternity Hospital, Cork, Ireland.
| | - Ellen O'Rourke
- Dept of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | | | - Eilidh Craig
- Rotunda Hospital, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Amy Worrall
- Rotunda Hospital, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Fergal O'Shaughnessy
- Rotunda Hospital, Dublin, Ireland; School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Jennifer Donnelly
- Rotunda Hospital, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Brian Cleary
- Rotunda Hospital, Dublin, Ireland; School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Fionnuala Ní Áinle
- Rotunda Hospital, Dublin, Ireland; University College Dublin, Dublin, Ireland
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18
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Chatterton CG, Fouad LA, Kline JA. Patient counseling for pulmonary embolism requires an individualized approach. Res Pract Thromb Haemost 2024; 8:102407. [PMID: 38694838 PMCID: PMC11060943 DOI: 10.1016/j.rpth.2024.102407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 02/13/2024] [Indexed: 05/04/2024] Open
Affiliation(s)
- Carolyn G. Chatterton
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Lina A. Fouad
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Jeffrey A. Kline
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
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19
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Connell PJ, Marquez Roa LA, Araujo-Duran J, Cheriyan M, Ayad S. Management of Acute Saddle Pulmonary Embolism in Pregnancy Following Fetal Surgery. Cureus 2024; 16:e54607. [PMID: 38523954 PMCID: PMC10959467 DOI: 10.7759/cureus.54607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2024] [Indexed: 03/26/2024] Open
Abstract
A 33-year-old gravidity three parity three (G3P3) woman at 34 weeks of pregnancy underwent fetal surgery to repair an open lumbosacral myelomeningocele at 22 weeks gestation and experienced preterm premature rupture of membranes as a result. She developed a saddle pulmonary embolus with signs of right heart strain while on prolonged bed rest. She was treated emergently with aspiration thrombectomy and suprarenal inferior vena cava (IVC) filter placement, followed by an uncomplicated cesarean delivery thereafter.
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Affiliation(s)
- Patrick J Connell
- Anesthesiology and Perioperative Medicine, Cleveland Clinic, Cleveland, USA
| | | | - Jorge Araujo-Duran
- Outcomes Research, Cleveland Clinic Fairview Hospital, Anesthesiology Institute, Cleveland, USA
| | | | - Sabry Ayad
- Outcomes Research, Cleveland Clinic, Cleveland, USA
- Anesthesiology, Cleveland Clinic, Cleveland, USA
- Anesthesiology, Cleveland Clinic Fairview Hospital, Cleveland, USA
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20
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Vuong ADB, Pham TH, Bui VH, Nguyen XT, Trinh NB, Nguyen YON, Le DKT, Nguyen PN. Successfully conservative management of the uterus in acute pulmonary embolism during cesarean section for placenta previa: a case report from Tu Du Hospital, Vietnam and literature review. Int J Emerg Med 2024; 17:14. [PMID: 38287235 PMCID: PMC10823749 DOI: 10.1186/s12245-024-00587-4] [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: 06/11/2023] [Accepted: 01/12/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Cardiopulmonary collapse is a catastrophic event in cesarean section, which leads to adverse outcomes for both the mother and the fetus. Pulmonary embolism is one of the rare etiologies of this entity. We herein reported the successful management of acute embolism pulmonary associated with cesarean delivery on a healthy pregnant woman at our tertiary referral hospital. CASE PRESENTATION A full-term pregnant woman hospitalized for planned cesarean delivery due to placenta previa without cardiorespiratory diseases. She was scheduled uneventfully for a planned cesarean section. After placental delivery, the patient spontaneously fell into cardiopulmonary collapse and her vital signs deteriorated rapidly. The obstetricians promptly completed the cesarean section and performed all procedures to prevent the PPH and preserve the uterus. At the same time, the anesthesiologists continued to carry out advanced heart-lung resuscitation in order to control her vital signs. After surgery, the multidisciplinary team assessed the patient and found a thrombus in her pulmonary circulation. Therefore, the patient was managed with therapeutic anticoagulation. The patient recovered in good clinical condition and was discharged after 2 weeks without any complications. CONCLUSIONS The diagnosis of acute pulmonary embolism is extremely difficult due to uncommon occurrence, sudden onset, and non-specific presentation. Awareness of this life-threatening pathology during cesarean delivery should be raised. Interdisciplinary assessment must be essentially established in this life-threatening condition. After the whole conventional management, uterine conservation may be acceptable where applicable. Further data is required to encourage this finding.
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Affiliation(s)
- Anh Dinh Bao Vuong
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam
| | - Thanh Hai Pham
- Tu Du Clinical Research Unit (TD-CRU), Tu Du Hospital, Ho Chi Minh City, Vietnam
| | - Van Hoang Bui
- Integrated Planning Room, Tu Du Hospital, Ho Chi Minh City, Vietnam
| | - Xuan Trang Nguyen
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam
| | - Ngoc Bich Trinh
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam
| | - Yen Oanh Ngoc Nguyen
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam
| | - Dang Khoa Tran Le
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam
| | - Phuc Nhon Nguyen
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam.
- Tu Du Clinical Research Unit (TD-CRU), Tu Du Hospital, Ho Chi Minh City, Vietnam.
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21
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Xiong W, Cheng Y, Zhao Y. Risk Scores in Venous Thromboembolism Guidelines of ESC, ACCP, and ASH: An Updated Review. Clin Appl Thromb Hemost 2024; 30:10760296241263856. [PMID: 38887044 PMCID: PMC11185021 DOI: 10.1177/10760296241263856] [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: 03/22/2024] [Revised: 05/24/2024] [Accepted: 06/07/2024] [Indexed: 06/20/2024] Open
Abstract
Venous thromboembolism (VTE) is associated with high morbidity and mortality. Risk scores associated with VTE have been widely used in clinical practice. Among numerous scores published, those included in guidelines are usually typical risk scores which have been extensively validated and globally recognized. This review provides an updated overview of the risk scores associated with VTE endorsed by 3 guidelines which are highly recognized in the field of VTE including the European Society of Cardiology, American College of Chest Physicians, and American Society of Hematology, focusing on the development, modification, validation, and comparison of these scores, to provide a comprehensive and updated understanding of all the classic risk scores associated with VTE to medical readers including but not limited to cardiologists, pulmonologists, hematologists, intensivists, physicians, surgeons, and researchers. Although each score recommended by these guidelines was more or less validated, there may still be room for further improvement. It may still be necessary to seek simpler, more practical, and more universally applicable VTE-related risk scores in the future.
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Affiliation(s)
- Wei Xiong
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yi Cheng
- Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yunfeng Zhao
- Department of Pulmonary and Critical Care Medicine, Punan Hospital, Pudong New District, Shanghai, China
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22
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Kevane B, Áinle FN. Prevention, diagnosis, and management of PE and DVT in pregnant women. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:237-247. [PMID: 38066865 PMCID: PMC10727078 DOI: 10.1182/hematology.2023000476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Venous thromboembolism (VTE) is a leading cause of maternal morbidity and mortality worldwide. Despite the impact of VTE on pregnant and postpartum people and on society, guidelines addressing prevention, diagnosis, and management of VTE in pregnant and postpartum people frequently are based on recommendations from expert opinion and are extrapolated from data in nonpregnant populations. Pregnant individuals are frequently excluded from clinical trials, which is a barrier to providing safe, effective care. Anchoring to a case discussion, this review provides an update on recently published and ongoing randomized clinical trials (RCTs), prospective clinical management studies, and other research in this area. It highlights, in particular, the results of the Highlow RCT, which addresses optimal prevention of recurrence during pregnancy in people with prior VTE. Finally, we raise awareness of the impact of national and international clinical trial networks on the conduct of RCTs in pregnancy. We conclude, based on these data, that academic VTE clinical trials in pregnant women can and must be done.
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Affiliation(s)
- Barry Kevane
- Department of Hematology, Mater University Hospital, Dublin, Ireland
- Department of Hematology, Rotunda Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
- Irish Network for VTE Research, University College Dublin, Dublin, Ireland
| | - Fionnuala Ní Áinle
- Department of Hematology, Mater University Hospital, Dublin, Ireland
- Department of Hematology, Rotunda Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
- Irish Network for VTE Research, University College Dublin, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
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23
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Oh JS, Jayasimhan D, Sithamparanathan S. Diagnostic test accuracy of D-dimer with or without a clinical decision rule in peripartum patients with suspected venous thromboembolism: A systematic review and meta-analysis. Intern Med J 2023; 53:2093-2101. [PMID: 36645305 DOI: 10.1111/imj.16021] [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: 08/31/2022] [Accepted: 01/12/2023] [Indexed: 01/17/2023]
Abstract
BACKGROUND Pregnancy and the peripartum period is a hypercoagulable state increasing the risk of venous thromboembolism (VTE). There may be a role in utilising D-dimer in the peripartum setting. AIMS The purpose of this review was to summarise the latest evidence regarding the diagnostic accuracy of D-dimer in the peripartum setting with or without the addition of clinical decision rules. METHODS We searched PubMed and CENTRAL databases to identify articles that included studies of women who had suspected VTE, underwent a D-dimer index test to rule out VTE and where radiological imaging or clinical follow-up, to a minimum of 30 days, was used as the reference standard. RESULTS We included 11 studies in the systematic review and meta-analysis. The log diagnostic odds ratio (DOR) for identifying VTE using D-dimer was 1.56 (95% confidence interval (CI) 0.59-2.52). The pooled sensitivity was 87% (95% CI 76.8-93%), specificity was 63.2% (95% CI 47.1-76.7%), and the area under receiver operator characteristic (ROC) curves was 0.76. We included four studies evaluating D-dimer combined with YEARS to detect VTE. The log DOR for identifying VTE using D-dimer combined with YEARS was 1.13 (95% CI 0.005-2.25). The pooled sensitivity was 89.8% (95% CI 60.2-98.1%), specificity was 65.7% (95% CI 54.7-75.2%) and the area under ROC for studies included with the YEARS clinical decision rule was 0.49. CONCLUSION This review highlighted that D-dimer use in the peripartum period for detection of VTE had a high sensitivity and high DOR but a poor area under ROC, which may limit its use in clinical practice.
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Affiliation(s)
- Jeong S Oh
- Department of Respiratory Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Dilip Jayasimhan
- Department of Respiratory Medicine, Auckland City Hospital, Auckland, New Zealand
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24
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Huang J, Namazy J. Diagnosis and Management of Asthma in Pregnancy-Reply. JAMA 2023; 330:1589. [PMID: 37874576 DOI: 10.1001/jama.2023.15282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Affiliation(s)
- Jenny Huang
- Department of Allergy, Asthma, and Immunology, Scripps Clinic, San Diego, California
| | - Jennifer Namazy
- Department of Allergy, Asthma, and Immunology, Scripps Clinic, San Diego, California
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25
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See KC. Diagnosis and Management of Asthma in Pregnancy. JAMA 2023; 330:1588. [PMID: 37874578 DOI: 10.1001/jama.2023.15279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Affiliation(s)
- Kay Choong See
- Division of Respiratory and Critical Care Medicine, National University Hospital, Singapore
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26
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Mathur C, Tohani A, Patil V, Khan A, Otigbah C. Postpartum maternal tachycardia - diagnostic pitfalls! Curr Opin Obstet Gynecol 2023; 35:395-402. [PMID: 37560779 DOI: 10.1097/gco.0000000000000895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
PURPOSE OF REVIEW Maternal tachycardia is a common sign with a multitude of causes. We attempt to look at the most common sinister ones in the postpartum period. RECENT FINDINGS Current guidelines differ in the definition of maternal tachycardia. It has been associated with adverse outcomes such as increased length of stay as well as higher mortality if there is underlying peripartum cardiomyopathy. Some recent studies look at common investigations and how these apply to peripartum women, such as ECG markers of arrhythmogenesis, reference ranges for PCT and echocardiogram findings during pregnancy prior to diagnosis of peripartum cardiomyopathy. SUMMARY Physiological changes make it difficult to interpret maternal tachycardia and thus how best to manage it. We propose the idea of a three-step approach for the assessment of patients, aiming to identify causes including tachyarrhythmias, obstetric haemorrhage, sepsis, venous thromboembolism and peripartum cardiomyopathy.The first step 'BEDSIDE' applies to all patients looking at observations, history and examination. The second step 'BASIC', applies to most patients and covers ECG and basic blood tests. The final step 'EXTRA' assesses the need for further investigations including additional blood tests and imaging. By using this model, clinicians and healthcare professionals should be able to rationalise the need for more invasive investigations whilst maintain good high-quality care.
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Affiliation(s)
| | | | | | - Ayub Khan
- Anaesthetic Consultant, Queen's Hospital
| | - Chineze Otigbah
- Obstetric and Gynaecology Consultant, Queen's Hospital Romford, Romford, UK
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27
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Bikdeli B, Muriel A, Wang Y, Piazza G, Khairani CD, Rosovsky RP, Mehdipoor G, O'Donoghue ML, Madridano O, Lopez-Saez JB, Mellado M, Brasero AMD, Grandone E, Spagnolo PA, Lu Y, Bertoletti L, López-Jiménez L, Núñez MJ, Blanco-Molina Á, Gerhard-Herman M, Goldhaber SZ, Bates SM, Jimenez D, Krumholz HM, Monreal M. Sex-Related Differences in Patient Characteristics, Risk Factors, and Symptomatology in Older Adults with Pulmonary Embolism: Findings from the SERIOUS-PE Study. Semin Thromb Hemost 2023; 49:725-735. [PMID: 36868268 DOI: 10.1055/s-0043-1764231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
Sex-specific factors are implicated in pulmonary embolism (PE) presentation in young patients, as indicated by increased risk in pregnancy. Whether sex differences exist in PE presentation, comorbidities, and symptomatology in older adults, the age group in which most PEs occur, remains unknown. We identified older adults (aged ≥65 years) with PE in a large international PE registry replete with information about relevant clinical characteristics (RIETE registry, 2001-2021). To provide national data from the United States, we assessed sex differences in clinical characteristics and risk factors of Medicare beneficiaries with PE (2001-2019). The majority of older adults with PE in RIETE (19,294/33,462, 57.7%) and in the Medicare database (551,492/948,823, 58.7%) were women. Compared with men, women with PE less frequently had atherosclerotic diseases, lung disease, cancer, or unprovoked PE, but more frequently had varicose veins, depression, prolonged immobility, or history of hormonal therapy (p < 0.001 for all). Women less often presented with chest pain (37.3 vs. 40.6%) or hemoptysis (2.4 vs. 5.6%) but more often with dyspnea (84.6 vs. 80.9%) (p < 0.001 for all). Measures of clot burden, PE risk stratification, and use of imaging modalities were comparable between women and men. PE is more common in elderly women than in men. Cancer and cardiovascular disease are more common in men, whereas transient provoking factors including trauma, immobility, or hormone therapy are more common in elderly women with PE. Whether such differences correlate with disparities in treatment or differences in short- or long-term clinical outcomes warrants further investigation.
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Affiliation(s)
- Behnood Bikdeli
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
- Cardiovascular Research Foundation (CRF), New York, New York
| | - Alfonso Muriel
- Department of Respiratory, Hospital Ramón y Cajal, Universidad de Alcalá (Instituto de Ramón y Cajal de Investigación Sanitaria), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal, IRYCIS, CIBERESP: Universidad de Alcalá, Madrid, Spain
| | - Yun Wang
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Candrika D Khairani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rachel P Rosovsky
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ghazaleh Mehdipoor
- Cardiovascular Research Foundation (CRF), New York, New York
- Division of Nuclear Medicine, Department of Radiology, Montefiore Medical Center, Bronx, New York
| | - Michelle L O'Donoghue
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- TIMI Study Group, Brigham and Women's Hospital, Boston, Massachusetts
| | - Olga Madridano
- Department of Internal Medicine, Hospital Universitario Infanta Sofía, Madrid, Spain
| | - Juan Bosco Lopez-Saez
- Department of Internal Medicine, Hospital Universitario de Puerto Real, Cádiz, Spain
| | - Meritxell Mellado
- Department of Angiology and Vascular Surgery, Hospital del Mar, Barcelona, Spain
| | - Ana Maria Diaz Brasero
- Department of Internal Medicine, Hospital Universitario de Guadalajara, Guadalajara, Spain
| | - Elvira Grandone
- Thrombosis and Haemostasis Unit, Fondazione I.R.C.C.S. "Casa Sollievo della Sofferenza," Foggia, S. Giovanni Rotondo, Italy
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
- Department of Obstetrics Gynaecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Primavera A Spagnolo
- Mary Horrigan Connors Center for Women's Health & Gender Biology, Harvard Medical School, Boston, Massachusetts
| | - Yuan Lu
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
| | - Laurent Bertoletti
- Department of Psychiatry, Brigham and Women Hospital, Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Saint-Etienne, France
- INSERM, CIC-1408, CHU Saint-Etienne, Saint-Etienne, France
| | | | - Manuel Jesús Núñez
- Department of Internal Medicine, Complejo Hospitalario de Pontevedra, Pontevedra, Spain
| | | | - Marie Gerhard-Herman
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shannon M Bates
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - David Jimenez
- Department of Respiratory, Hospital Ramón y Cajal, Universidad de Alcalá (Instituto de Ramón y Cajal de Investigación Sanitaria), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Harlan M Krumholz
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
- Department of Health Policy and Administration, Yale School of Public Health, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Manuel Monreal
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM - Universidad Católica San Antonio de Murcia, Murcia, Spain
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28
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Zou B, Zou F, Cai J. An efficient machine learning framework to identify important clinical features associated with pulmonary embolism. PLoS One 2023; 18:e0292185. [PMID: 37768933 PMCID: PMC10538737 DOI: 10.1371/journal.pone.0292185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 09/14/2023] [Indexed: 09/30/2023] Open
Abstract
A misdiagnosis of pulmonary embolism (PE) can have severe consequences such as disability or death. It's crucial to accurately identify key clinical features of PE in clinical practice to promptly identify potential PE patients who may present asymptomatically, and to prevent misdiagnosing PE as asthma exacerbation in patients with symptoms like dyspnea or chest pain. However, reliably identifying these important features can be challenging due to many factors influencing the likelihood of PE development in complex fashions (e.g., the interactions among these factors). To address this difficulty, we presented an effective framework using the deep neural network (DNN) model and the permutation-based feature importance test (PermFIT) procedure, i.e., PermFIT-DNN. We applied the PermFIT-DNN framework to the analysis of data from a PE study for asthma exacerbation patients. Our analysis results show that the PermFIT-DNN framework can robustly identify key features for classifying PE status. The important features identified can also aid in accurately predicting the PE risk.
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Affiliation(s)
- Baiming Zou
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Fei Zou
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Jianwen Cai
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
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29
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Westafer LM, Long B, Gottlieb M. Managing Pulmonary Embolism. Ann Emerg Med 2023; 82:394-402. [PMID: 36805291 PMCID: PMC10432572 DOI: 10.1016/j.annemergmed.2023.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 02/19/2023]
Affiliation(s)
- Lauren M Westafer
- Department for Healthcare Delivery and Population Science and Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA.
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
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30
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Righini M, Suhl J. Update on venous thromboembolism in pregnancy. JOURNAL DE MEDECINE VASCULAIRE 2023; 48:97-99. [PMID: 37914460 DOI: 10.1016/j.jdmv.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 09/30/2023] [Indexed: 11/03/2023]
Affiliation(s)
- M Righini
- Geneva University Hospitals, Faculty of Medicine, Division of Angiology and Hemostasis, Geneva, Switzerland
| | - J Suhl
- Private Practice, Bastia, France.
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31
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Meaney C, Stroer K, Perdue M, Walker J, Umar M, Mitchell C. Use of YEARS Algorithm in Military Health Care Beneficiaries to Evaluate Use of Computed Tomography Pulmonary Angiography. Mil Med 2023; 188:e2380-e2386. [PMID: 36350772 DOI: 10.1093/milmed/usac332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/06/2022] [Accepted: 10/12/2022] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION Pulmonary embolism (PE) can be difficult to rule out without computed tomography pulmonary angiograms (CTPAs), as presentations vary. Multiple clinical decision rules (CDRs) exist to risk-stratify patients to avoid unnecessary CTPAs. However, the currently used CDRs are complex, and research has shown low compliance with their usage. The YEARS algorithm is less complex and excludes patients from CTPA if PE is not the most likely diagnosis, they do not have a history of hemoptysis, and no clinical signs of deep vein thrombosis, is less complex. However, no studies have evaluated YEARS in the U.S. Military health care beneficiary population. Therefore, this study sought to determine if implementing the YEARS algorithm could decrease the number of CTPAs ordered to rule out PE in low-risk patients. METHODS This retrospective, single-center cohort study applied the YEARS algorithm to low-risk military beneficiaries presenting to the emergency department in the calendar year 2020 at a single U.S. Army MTF. The primary outcome was the number of CTPAs indicated by the YEARS algorithm versus the number ordered via standard practice. We used chi-square testing to compare the number of subjects in whom YEARS indicated CTPA (meets criteria/does not meet criteria) versus the actual number of subjects who underwent CTPA (meets criteria/does not meet criteria). The secondary outcomes included applying YEARS similarly to the number of subjects >50 years of age (as opposed to age-adjusted d-dimer), determining the number of pregnant patients who could have avoided CTPA via application of YEARS, and assessing possible cost savings via reduction of CTPA. RESULTS We included 353 subjects during the study period, 271 of whom underwent CTPA. YEARS would have only indicated 25 of them, P = .018. In patients >50 years of age, 164 underwent CTPA versus nine who met YEARS criteria, P = .014. Among pregnant patients, six underwent CTPA versus one who YEARS would have indicated, P = .130. Application of the YEARS algorithm would have led to a 90.8% reduction in CTPAs ordered with an overall known missed PE rate of 1.1%. Applying the YEARS algorithm in 2020 could have led to 246 fewer CTPAs at a minimum cost savings of $38,762.22 for the MTF based on the coded billing cost of $157.57 per CTPA when local staff radiologists performed image interpretation. This estimate does not consider the additional undisclosed cost of contracted radiologists interpreting after regular duty hours. CONCLUSIONS For our military beneficiaries, our study indicates that the YEARS algorithm would have reduced CTPA utilization in all age ranges and potentially among pregnant patients with a known missed PE rate of 1.1%.
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Affiliation(s)
- Colleen Meaney
- Emergency Medicine Physician Assistant Residency Program, Carl R. Darnall Army Medical Center, Fort Hood, TX 76544, USA
| | - Kenneth Stroer
- Emergency Medicine Residency Program, Carl. R. Darnall Army Medical Center, Fort Hood, TX 76544, USA
| | - Matthew Perdue
- Emergency Medicine Physician Assistant Residency Program, Carl R. Darnall Army Medical Center, Fort Hood, TX 76544, USA
| | - Jerimiah Walker
- Emergency Medicine Physician Assistant Residency Program, Carl R. Darnall Army Medical Center, Fort Hood, TX 76544, USA
| | - Mohamad Umar
- Emergency Medicine Physician Assistant Residency Program, Carl R. Darnall Army Medical Center, Fort Hood, TX 76544, USA
| | - Christopher Mitchell
- Emergency Medicine Residency Program, Carl. R. Darnall Army Medical Center, Fort Hood, TX 76544, USA
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32
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Varrias D, Spanos M, Kokkinidis DG, Zoumpourlis P, Kalaitzopoulos DR. Venous Thromboembolism in Pregnancy: Challenges and Solutions. Vasc Health Risk Manag 2023; 19:469-484. [PMID: 37492280 PMCID: PMC10364824 DOI: 10.2147/vhrm.s404537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/13/2023] [Indexed: 07/27/2023] Open
Abstract
Venous thromboembolism (VTE) is a serious medical condition that can lead to severe morbidity and mortality, making it a significant public health concern. VTE is a multifactorial condition that results from the interaction of genetic, acquired, and environmental factors. Physiological changes during pregnancy increase the risk of VTE as they express Virchow's triad (increased coagulation factors, decreased fibrinolysis, trauma, and venous stasis). Moreover, pregnancy-related risk factors, such as advanced maternal age, obesity, multiple gestations, and cesarean delivery, further increase the risk of VTE. Managing VTE in pregnancy is challenging due to the complexity of balancing the risks and benefits of anticoagulant therapy for both the mother and the fetus. A multidisciplinary approach involving obstetricians, hematologists, and neonatologists, is necessary to ensure optimal outcomes for both the mother and baby. This review aims to discuss the current challenges associated with VTE in pregnancy and identify potential solutions for improving outcomes for pregnant women at risk for VTE.
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Affiliation(s)
- Dimitrios Varrias
- Department of Medicine, Jacobi Medical Center, Bronx, NY, 10461, USA
- Albert Einstein College of Medicine, Bronx, NY, 10461, USA
| | - Michail Spanos
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Panagiotis Zoumpourlis
- Department of Medicine, Jacobi Medical Center, Bronx, NY, 10461, USA
- Albert Einstein College of Medicine, Bronx, NY, 10461, USA
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Mihajlovic S, Trifunovic Kubat J, Nikolic D, Santric-Milicevic M, Milicic B, Dimic N, Lackovic M. Risk Factors of Adverse Maternal Outcome among SARS-CoV-2 Infected Critically Ill Pregnant Women in Serbia. J Clin Med 2023; 12:3902. [PMID: 37373597 DOI: 10.3390/jcm12123902] [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: 04/18/2023] [Revised: 05/15/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND AND OBJECTIVES During the COVID-19 pandemic, Serbia has faced devastating losses related to increased mortality rates among men and women of all ages. With 14 registered cases of maternal death in 2021, it became obvious that pregnant women are faced with a serious threat that jeopardises their life as well as the life of their unborn child. Studying the consequences of the COVID-19 pandemic on maternal outcomes is vivifying and stimulating for many professionals and decision-makers, and knowing the contextual characteristics can facilitate the application of literature findings in practice. Therefore, the aim of this study was to present findings of maternal mortality in Serbia associated with SARS-CoV-2 infected and critically ill pregnant women. METHODS Clinical status and pregnancy-related features were analysed for a series of 192 critically ill pregnant women with confirmed SARS-CoV-2 infection. According to the treatment outcome, pregnant women were divided in two study groups: a group of survivors and a group of deceased patients. RESULTS A lethal outcome was recorded in seven cases. Pregnant women in the deceased group were presenting at admission more commonly with X-ray-confirmed pneumonia, a body temperature of >38 °C, cough, dyspnea, and fatigue. They were more likely to have a progression of the disease, to be admitted to intensive care unit, and be dependent from mechanical ventilation, as well as to have nosocomial infection, pulmonary embolism, and postpartum haemorrhage. On average, they were in their early third trimester of pregnancy, presenting more commonly with gestational hypertension and preeclampsia. CONCLUSIONS Initial clinical manifestations of SARS-CoV-2 infection, such as dyspnea, cough, fatigue, and fever, could be a potent factors in risk stratification and outcome prediction. Prolonged hospitalization, ICU admission, and associated risk of hospital-acquired infections require strict microbiological surveillance and should be a constant reminder of rational antibiotics use. Understanding and identification of risk factors associated with poor maternal outcomes among pregnant women infected with SARS-CoV-2 should warn medical professionals of potentially unwanted outcomes and can be used for organising an individualised treatment for a pregnant patient's specific needs, including a guide to necessary consultations with medical specialists in various fields.
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Affiliation(s)
- Sladjana Mihajlovic
- Department of Obstetrics and Gynecology, University Hospital "Dragisa Misovic", 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Jelena Trifunovic Kubat
- Department of Obstetrics and Gynecology, University Hospital "Dragisa Misovic", 11000 Belgrade, Serbia
| | - Dejan Nikolic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Department of Physical Medicine and Rehabilitation, University Children's Hospital, 11000 Belgrade, Serbia
| | - Milena Santric-Milicevic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Institute of Social Medicine, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Faculty of Medicine, School of Public Health and Health Management, University of Belgrade, 11000 Belgrade, Serbia
| | - Biljana Milicic
- Department of Medical Statistics and Informatics, School of Dental Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Nemanja Dimic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Clinic for Anesthesiology and Intensive Care, University Hospital "Dragisa Misovic", 11000 Belgrade, Serbia
| | - Milan Lackovic
- Department of Obstetrics and Gynecology, University Hospital "Dragisa Misovic", 11000 Belgrade, Serbia
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Webster LA, Bishay V. Venous Thromboembolism Management in Pregnant Patients. Tech Vasc Interv Radiol 2023; 26:100901. [PMID: 37865451 DOI: 10.1016/j.tvir.2023.100901] [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] [Indexed: 10/23/2023]
Abstract
Pulmonary embolism (PE) in pregnancy accounts for 10% of maternal deaths in the United States. As maternal morbidity and mortality continue to increase, it is imperative for all specialties interfacing with pregnant patients to understand the current research and guidelines surrounding risk stratification, diagnosis, and treatments of PE in pregnancy. Given the complexity of high-risk pregnancy-associated PE (PA-PE), that is, which is associated with hemodynamic instability or collapse, and the rising popularity of new technologies to treat high-risk PA-PE in the nonpregnant population, this review aims to emphasize the differences in diagnosis, risk stratification, and management of the pregnant and nonpregnant PE patients. Furthermore, this review will cover treatment paradigms that include anticoagulation versus advanced therapies such as systemic thrombolysis, surgical embolectomy, extracorporeal membrane oxygenation, and inferior vena cava disruption as well as the more novel therapies which fall under the umbrella term of catheter-based treatments. Finally, this review will include a case-based review of 2 patients with PA-PE requiring catheter-based therapies and their ultimate clinical outcomes.
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Affiliation(s)
- Linzi A Webster
- Division of Vascular and Interventional Radiology, Department of Diagnostic, Molecular & Interventional Radiology, Mount Sinai Health System, New York, NY
| | - Vivian Bishay
- Division of Vascular and Interventional Radiology, Department of Diagnostic, Molecular & Interventional Radiology, Mount Sinai Health System, New York, NY.
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35
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Duffy J, Berger FH, Cheng I, Shelton D, Galanaud JP, Selby R, Laing K, Fedorovsky T, Matelski J, Hall J. Implementation of the YEARS algorithm to optimise pulmonary embolism diagnostic workup in the emergency department. BMJ Open Qual 2023; 12:bmjoq-2022-002119. [PMID: 37217241 DOI: 10.1136/bmjoq-2022-002119] [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: 09/03/2022] [Accepted: 04/29/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Excessive use of CT pulmonary angiography (CTPA) to investigate pulmonary embolism (PE) in the emergency department (ED) contributes to adverse patient outcomes. Non-invasive D-dimer testing, in the context of a clinical algorithm, may help decrease unnecessary imaging but this has not been widely implemented in Canadian EDs. AIM To improve the diagnostic yield of CTPA for PE by 5% (absolute) within 12 months of implementing the YEARS algorithm. MEASURES AND DESIGN Single centre study of all ED patients >18 years investigated for PE with D-dimer and/or CTPA between February 2021 and January 2022. Primary and secondary outcomes were the diagnostic yield of CTPA and frequency of CTPA ordered compared with baseline. Process measures included the percentage of D-dimer tests ordered with CTPA and CTPAs ordered with D-dimers <500 µg/L Fibrinogen Equivalent Units (FEU). The balancing measure was the number of PEs identified on CTPA within 30 days of index visit. Multidisciplinary stakeholders developed plan- do-study-act cycles based on the YEARS algorithm. RESULTS Over 12 months, 2695 patients were investigated for PE, of which 942 had a CTPA. Compared with baseline, the CTPA yield increased by 2.9% (12.6% vs 15.5%, 95% CI -0.06% to 5.9%) and the proportion of patients that underwent CTPA decreased by 11.4% (46.4% vs 35%, 95% CI -14.1% to -8.8%). The percentage of CTPAs ordered with a D-dimer increased by 26.3% (30.7% vs 57%, 95% CI 22.2% 30.3%) and there were two missed PE (2/2695, 0.07%). IMPACT Implementing the YEARS criteria may safely improve the diagnostic yield of CTPAs and reduce the number of CTPAs completed without an associated increase in missed clinically significant PEs. This project provides a model for optimising the use of CTPA in the ED.
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Affiliation(s)
- Juliana Duffy
- Division of Emergency Medicine, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ferco Henricus Berger
- Department of Medical Imaging, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ivy Cheng
- Division of Emergency Medicine, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Dominick Shelton
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Family & Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jean-Philippe Galanaud
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rita Selby
- Department of Laboratory Medicine & Pathobiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Laboratory Medicine & Pathobiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kristine Laing
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Tali Fedorovsky
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John Matelski
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Justin Hall
- Division of Emergency Medicine, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Mihajlovic S, Nikolic D, Milicic B, Santric-Milicevic M, Glushkova N, Nurgalieva Z, Lackovic M. Association of Pre-Pregnancy Obesity and COVID-19 with Poor Pregnancy Outcome. J Clin Med 2023; 12:jcm12082936. [PMID: 37109271 PMCID: PMC10144693 DOI: 10.3390/jcm12082936] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/16/2023] [Accepted: 03/21/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND AND OBJECTIVES During the COVID-19 pandemic, a possible overlap of obesity and COVID-19 infection has raised concerns among patients and healthcare professionals about protecting pregnant women from developing a severe infection and unwanted pregnancy outcomes. The aim of this study was to evaluate the associations of body mass index with clinical, laboratory, and radiology diagnostic parameters as well as pregnancy complications and maternal outcomes in pregnant patients with COVID-19. MATERIALS AND METHODS Clinical status, laboratory, and radiology diagnostic parameters and pregnancy outcomes were analyzed for pregnant women hospitalized between March 2020 and November 2021 in one tertiary-level university clinic in Belgrade, Serbia, due to infection with SARS-CoV-2. Pregnant women were divided into the three sub-groups according to their pre-pregnancy body mass index. For testing the differences between groups, a two-sided p-value <0.05 (the Kruskal-Wallis and ANOVA tests) was considered statistically significant. RESULTS Out of 192 hospitalized pregnant women, obese pregnant women had extended hospitalizations, including ICU duration, and they were more likely to develop multi-organ failure, pulmonary embolism, and drug-resistant nosocomial infection. Higher maternal mortality rates, as well as poor pregnancy outcomes, were also more likely to occur in the obese group of pregnant women. Overweight and obese pregnant women were more likely to develop gestational hypertension, and they had a higher grade of placental maturity. CONCLUSIONS Obese pregnant women hospitalized due to COVID-19 infection were more likely to develop severe complications.
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Affiliation(s)
- Sladjana Mihajlovic
- University Hospital "Dragisa Misovic", Heroja Milana Tepica 1, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Dejan Nikolic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Department of Physical Medicine and Rehabilitation, University Children's Hospital, 11000 Belgrade, Serbia
| | - Biljana Milicic
- Department of Medical Statistics and Informatics, School of Dental Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Milena Santric-Milicevic
- Institute of Social Medicine, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Center-School of Public Health and Health Management, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Natalya Glushkova
- Faculty of Medicine and Health Care, Al-Farabi Kazakh National University, Almaty 050044, Kazakhstan
| | - Zhansaya Nurgalieva
- Faculty of Medicine and Health Care, Al-Farabi Kazakh National University, Almaty 050044, Kazakhstan
| | - Milan Lackovic
- University Hospital "Dragisa Misovic", Heroja Milana Tepica 1, 11000 Belgrade, Serbia
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Jianling Q, Lulu J, Liuyi Q, Lanfang F, Xu M, Wenchen L, Maofeng W. A nomogram for predicting the risk of pulmonary embolism in neurology department suspected PE patients: A 10-year retrospective analysis. Front Neurol 2023; 14:1139598. [PMID: 37090975 PMCID: PMC10113433 DOI: 10.3389/fneur.2023.1139598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 03/06/2023] [Indexed: 04/08/2023] Open
Abstract
ObjectiveThe purpose of this retrospective study was to establish a numerical model for predicting the risk of pulmonary embolism (PE) in neurology department patients.MethodsA total of 1,578 subjects with suspected PE at the neurology department from January 2012 to December 2021 were considered for enrollment in our retrospective study. The patients were randomly divided into the training cohort and the validation cohort in the ratio of 7:3. The least absolute shrinkage and selection operator regression were used to select the optimal predictive features. Multivariate logistic regression was used to establish the numerical model, and this model was visualized by a nomogram. The model performance was assessed and validated by discrimination, calibration, and clinical utility.ResultsOur predictive model indicated that eight variables, namely, age, pulse, systolic pressure, hemoglobin, neutrophil count, low-density lipoprotein, D-dimer, and partial pressure of oxygen, were associated with PE. The area under the receiver operating characteristic curve of the model was 0.750 [95% confidence interval (CI): 0.721–0.783] in the training cohort and 0.742 (95% CI: 0.689–0.787) in the validation cohort, indicating that the model showed a good differential performance. A good consistency between the prediction and the real observation was presented in the training and validation cohorts. The decision curve analysis in the training and validation cohorts showed that the numerical model had a good net clinical benefit.ConclusionWe established a novel numerical model to predict the risk factors for PE in neurology department suspected PE patients. Our findings may help doctors to develop individualized treatment plans and PE prevention strategies.
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Affiliation(s)
- Qiang Jianling
- Department of Biomedical Sciences Laboratory, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, China
| | - Jin Lulu
- Department of Biomedical Sciences Laboratory, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, China
| | - Qiu Liuyi
- Department of Pathology, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, China
| | - Feng Lanfang
- Department of Respiratory, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, China
| | - Ma Xu
- Department of Vascular Surgery, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, China
| | - Li Wenchen
- Department of Neurology, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, China
| | - Wang Maofeng
- Department of Biomedical Sciences Laboratory, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, China
- *Correspondence: Wang Maofeng
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Roy PM, Moumneh T, Bizouard T, Duval D, Douillet D. How to Combat Over-Testing for Patients Suspected of Pulmonary Embolism: A Narrative Review. Diagnostics (Basel) 2023; 13:diagnostics13071326. [PMID: 37046544 PMCID: PMC10093278 DOI: 10.3390/diagnostics13071326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/26/2023] [Accepted: 03/30/2023] [Indexed: 04/05/2023] Open
Abstract
The diagnosis of PE remains difficult in 2023 because the signs and symptoms are not sensible nor specific. The consequences of potential diagnostic errors can be dramatic, whether by default or by excess. Furthermore, the achievement of a simple diagnostic strategy, based on clinical probability assessment, D-dimer measurement and computed tomography pulmonary angiography (CTPA) leads to a new challenge for PE diagnosis: over-testing. Indeed, since the 2000s, the wide availability of CTPA resulted in a major increase in investigations with a mod I confirm erate increase in PE diagnosis, without any notable improvement in patient outcomes. Quite the contrary, the complications of anticoagulation for PE increased significantly, and the long-term consequences of imaging diagnostic radiation is an important concern, especially the risk of breast cancer for young women. As a result, several strategies have been proposed to fight over-testing. They are mostly based on defining a subgroup of patients for whom no specific exam should be required to rule-out PE and adjusting the D-dimer cutoff to allow the exclusion of PE without performing CTPA. This narrative review presents the advantages and limitations of these different strategies as well as the perspective in PE diagnosis.
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Affiliation(s)
- Pierre-Marie Roy
- Department of Emergency Medicine, University Hospital of Angers, Avenue of the Hotel Dieu, 49100 Angers, France
- UMR MitoVasc CNRS 6215 INSERM 1083, University Angers, 49100 Angers, France
- FCRIN, INNOVTE, 42023 Saint-Étienne, France
| | - Thomas Moumneh
- Department of Emergency Medicine, University Hospital of Tours, Avenue of the Republic, 37044 Tours, France
| | - Thomas Bizouard
- Department of Emergency Medicine, University Hospital of Angers, Avenue of the Hotel Dieu, 49100 Angers, France
| | - Damien Duval
- Department of Emergency Medicine, University Hospital of Angers, Avenue of the Hotel Dieu, 49100 Angers, France
| | - Delphine Douillet
- Department of Emergency Medicine, University Hospital of Angers, Avenue of the Hotel Dieu, 49100 Angers, France
- UMR MitoVasc CNRS 6215 INSERM 1083, University Angers, 49100 Angers, France
- FCRIN, INNOVTE, 42023 Saint-Étienne, France
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Cueto-Robledo G, Cervantes-Naranjo FD, Gonzalez-Hermosillo LM, Roldan-Valadez E, Graniel-Palafox LE, Castro-Escalante KY, Orozco-Zuñiga B. Pulmonary embolism during pregnancy: an updated review with case series description. Curr Probl Cardiol 2023; 48:101683. [PMID: 36898596 DOI: 10.1016/j.cpcardiol.2023.101683] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/02/2023] [Indexed: 03/12/2023]
Abstract
Pulmonary embolism (PE) is a potentially life-threatening condition that can occur during pregnancy and pose a significant risk to the mother and the developing fetus. It is a major contributor to pregnancy-related morbidity and mortality in any trimester. It is estimated that the incidence of PE during pregnancy is approximately 1 in 1000 pregnancies. The mortality rate for pregnant women with PE is about 3%, significantly higher than that for non-pregnant women with PE. Overall, the topic of PE and pregnancy is essential for healthcare professionals to be aware of the risks, signs, and treatment options to improve outcomes and ensure the best possible care for both the mother and the developing fetus. To prevent the fatal condition, the physician is encouraged when there is a suspicion of the pathology. This report presents an updated comprehensive review of PE during pregnancy, discussing critical aspects of the clinical and imaging diagnosis, use of heparin, thrombolysis, and prevention. We believe this article will be helpful for cardiologists, obstetricians, and other health-related professionals.
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Affiliation(s)
- Guillermo Cueto-Robledo
- Cardiorespiratory Emergencies, Hospital General de México "Dr Eduardo Liceaga", 06720, Mexico City, Mexico; Pulmonary Circulation Clinic, Hospital General de México "Dr. Eduardo Liceaga", 06720, Mexico City, Mexico; Faculty of Medicine, National Autonomous University of Mexico, 04510, Mexico City, Mexico.
| | | | | | - Ernesto Roldan-Valadez
- Directorate of Research, Hospital General de Mexico "Dr. Eduardo Liceaga," 06720, Mexico City, Mexico; I.M. Sechenov First Moscow State Medical University (Sechenov University), Department of Radiology, 119992, Moscow, Russia.
| | | | | | - Benjamin Orozco-Zuñiga
- Ginecology Department, Hospital General de México ¨Dr. Eduardo Liceaga¨, Mexico City, Mexico.
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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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Sawyer JM, Moridzadeh N, Bavolek RA. Cardiovascular Complications of Pregnancy. Emerg Med Clin North Am 2023; 41:247-258. [PMID: 37024161 DOI: 10.1016/j.emc.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
The physiologic changes in pregnancy predispose the pregnant patient to a variety of potential cardiovascular complications. In this article, we discuss the major cardiovascular disorders of pregnancy and their management, highlight specific diagnostic challenges, and discuss new developments in the field. Topics covered in this article include venous thromboembolism, acute myocardial infarction, peripartum cardiomyopathy, and aortic dissection.
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Affiliation(s)
- John Mark Sawyer
- UCLA Ronald Reagan, Olive View Emergency Medicine Residency, 1100 Glendon Avenue, Suite 1200, Los Angeles, CA 90024, USA.
| | | | - Rebecca A Bavolek
- UCLA Ronald Reagan, Olive View Emergency Medicine Residency, 1100 Glendon Avenue, Suite 1200, Los Angeles, CA 90024, USA
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Gillespie CD, Yates A, Murphy MC, Hughes M, Ewins K, NíAinle F, Bolster F, Rowan M, Foley S, MacMahon PJ. Breast Shielding Combined With an Optimized Computed Tomography Pulmonary Angiography Pregnancy Protocol: A Special Use-Case for Shielding? J Thorac Imaging 2023; 38:36-43. [PMID: 36162076 DOI: 10.1097/rti.0000000000000677] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To determine the impact of breast shields on breast dose and image quality when combined with a low-dose computed tomography pulmonary angiography (CTPA) protocol for pregnancy. METHODS A low-dose CTPA protocol, with and without breast shields, was evaluated by anthropomorphic phantom and 20 prospectively recruited pregnant participants from January to October 2019. Thermoluminescent dosimeters measured surface and absorbed breast dose in the phantom and surface breast dose in participants. The Monte-Carlo method estimated the absorbed breast dose in participants. Image quality was assessed quantitatively by regions of interest analysis and subjectively by the Likert scale. Doses and image quality for CTPA alone were compared with CTPA with breast shields. RESULTS Mean surface and absorbed breast dose for CTPA alone were 1.3±0.4 and 2.8±1.5 mGy in participants, and 1.5±0.7 and 1.6±0.6 mGy in the phantom. Shielding reduced surface breast dose to 0.5±0.3 and 0.7±0.2 mGy in the phantom (66%) and study participants (48%), respectively. Absorbed breast dose reduced to 0.9±0.5 mGy (46%) in the phantom.Noise increased with breast shields at lower kV settings (80 to 100 kV) in the phantom; however, in study participants there was no significant difference between shield and no-shield groups for main pulmonary artery noise (no-shield: 34±9.8, shield: 36.3±7.2, P =0.56), SNR (no-shield: 11.2±3.7, shield: 10.8±2.6, P =0.74) or contrast-to-noise ratio (no-shield: 10.0±3.3, shield: 9.3±2.4, P =0.6). Median subjective image quality scores were comparable (no-shield: 4.0, interquartile range: 3.5 to 4.4, shield: 4.3, interquartile range: 4.0 to 4.5). CONCLUSION Combining low-dose CTPA with breast shields confers additional breast-dose savings without impacting image quality and yields breast doses approaching those of low-dose scintigraphy, suggesting breast shields play a role in protocol optimization for select groups.
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Affiliation(s)
| | | | | | | | - Karl Ewins
- Haematology, Mater Misericordiae University Hospital
| | | | - Ferdia Bolster
- Departments of Radiology
- School of Medicine, University College Dublin
| | - Michael Rowan
- Department of Medical Physics, St James Hospital, Dublin, Ireland
| | - Shane Foley
- Radiography & Diagnostic Imaging, School of Medicine, University College Dublin
| | - Peter J MacMahon
- Departments of Radiology
- School of Medicine, University College Dublin
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Wauthier L, Favresse J, Hardy M, Douxfils J, Le Gal G, Roy P, van Es N, Ay C, ten Cate H, Lecompte T, Lippi G, Mullier F. D-dimer testing: A narrative review. Adv Clin Chem 2023. [DOI: 10.1016/bs.acc.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
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McCandlish JA, Naidich JJ, Feizullayeva C, Makhnevich A, Barish MA, Sanelli PC, Cohen SL. Utilization of a Guideline-recommended Imaging Paradigm for Pregnant Patients With Suspicion of Pulmonary Embolism. J Thorac Imaging 2023; 38:23-28. [PMID: 36162078 DOI: 10.1097/rti.0000000000000676] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE A dose reduction imaging paradigm utilizing chest x-ray (CXR) to triage between computed tomography pulmonary angiography (CTPA) and lung scintigraphy (LS) was introduced in 2001 and adopted in 2012 by the American Thoracic Society/Society of Thoracic Radiology (ATS) guideline for the evaluation of pulmonary embolism in pregnancy. We aimed to assess the utilization of this imaging paradigm preadoption and postadoption by the ATS guideline, and identify factors associated with its utilization. MATERIALS AND METHODS This retrospective cohort study evaluated consecutive pregnant patients who received CTPA or LS for the evaluation of pulmonary embolism in pregnancy at 2 tertiary hospitals between September 2008 and March 2017, excluding 2012 for guideline release washout. Utilization of the imaging paradigm was defined per patient by the use of CXR before advanced imaging, with CTPA performed following positive CXR and LS performed following negative CXR. Multivariate analyses were performed to assess factors associated with utilization of the imaging paradigm. P <0.05 is considered significant. RESULTS Overall, 9.8% (63/643) of studies utilized the dose reduction imaging paradigm, 13.3% (34/256) before the guidelines, and 7.5% (29/387) after. Multivariable analysis showed that the dose reduction imaging paradigm utilization was higher for inpatients (odds ratio [OR]: 4.5) and outpatients (OR: 3.1) relative to the emergency department patients, and lower for second (OR: 0.3) and third (OR: 0.2) trimester patients, without significant differences by study priority, patient age, or patient race. CONCLUSIONS Guideline-recommended dose reduction imaging paradigm utilization was low, and decreased after guideline publication. Utilization varied by patient setting and trimester, which are potential targets for interventions to improve guideline compliance.
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Affiliation(s)
| | - Jason J Naidich
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead
- Department of Radiology, North Shore University Hospital/Northwell Health
| | - Chinara Feizullayeva
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR) at Northwell Health
- Center for Health Innovations and Outcomes Research (CHIOR) at Northwell Health
- The Feinstein Institute for Medical Research at Northwell Health, Manhasset, NY
| | | | - Matthew A Barish
- Department of Radiology, North Shore University Hospital/Northwell Health
| | - Pina C Sanelli
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead
- Department of Radiology, North Shore University Hospital/Northwell Health
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR) at Northwell Health
- Center for Health Innovations and Outcomes Research (CHIOR) at Northwell Health
- The Feinstein Institute for Medical Research at Northwell Health, Manhasset, NY
| | - Stuart L Cohen
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead
- Department of Radiology, North Shore University Hospital/Northwell Health
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR) at Northwell Health
- Center for Health Innovations and Outcomes Research (CHIOR) at Northwell Health
- The Feinstein Institute for Medical Research at Northwell Health, Manhasset, NY
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Kusuma AANJ, Putra IGM, Suardika A, Novrita Sari A. Clinical Overview in Pregnancy with COVID-19 at prof. Dr. I.G.N.G. Ngoerah Hospital Period of April 2020-March 2021. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.11022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND: Pregnant women are one of the populations that are susceptible to coronavirus disease 2019 (COVID-19) infection due to physiological changes during pregnancy that is an adaptive response to pregnancy such as diaphragmatic elevation, increased oxygen consumption, and airway mucosal edema which can also make pregnant women more intolerant of hypoxia. In addition to being vulnerable, COVID-19 in pregnant women may have a different clinical course from the general population.
AIM: This study aims to determine the demographic and clinical characteristics in pregnancy with COVID-19 at Prof. Dr. I.G.N.G. Ngoerah Hospital, Bali, Indonesia.
METHODS: This study was a cross-sectional descriptive study using secondary data derived from patient medical records and carried out in the delivery room and medical record installation at Prof. Dr. I.G.N.G. Ngoerah Hospital, Bali, Indonesia, for the period of April 1, 2020–March 31, 2021.
RESULTS: Of the 275 patients, most were in the age range of 26–30 years (46.55%), in the third trimester (81.45%), and patients came alone (54.18%). Most of the patients came without symptoms with reactive rapid antibody results (60.97%). Of the 197 patients who delivered, 84.77% had CS and 66.55% without oxygen therapy. About 69.69% of patients experienced complications and the mortality rate was 1.09%. The highest birth weight was >2500 g by 76.8%, with the good neonatal outcome (82.92%) and negative swab results (89.45%). Inflammatory markers tend to increase as symptoms increase. Neutrophil-to-lymphocyte ratio, procalcitonin, and ferritin were markedly increased from moderate symptoms to severe-critical symptoms. The same was true for ferritin levels, where there was a sharp rise in significant symptoms. Meanwhile, procalcitonin levels have started to increase quite strikingly from moderate symptoms to the highest in severe symptoms.
CONCLUSION: It is hoped that this demographic and clinical picture would further our understanding of COVID-19 and help us develop methods to lessen the disease’s severity and spread to enhance maternal and newborn outcomes.
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46
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Pulmonary embolism in pregnancy and the puerperium. Best Pract Res Clin Obstet Gynaecol 2022; 85:96-106. [PMID: 35872145 DOI: 10.1016/j.bpobgyn.2022.06.003] [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: 05/11/2022] [Accepted: 06/20/2022] [Indexed: 12/14/2022]
Abstract
Pulmonary embolism (PE) in pregnant women appears to be increasing. This could be related in part to improved health care allowing more women with risk factors to conceive, as well as increase in the high-risk groups which include pregnancies conceived on artificial reproductive technology, advancing maternal age, obesity, and caesarean deliveries. Prevention and early diagnosis with prompt effective treatment can reduce maternal mortality and improve pregnancy outcome, so that obstetricians should be on the lookout for venous thrombosis and PE, especially when in the majority of cases, risk factors only start to emerge or develop in the course of pregnancy and delivery. Management includes accurate diagnosis with ventilation/perfusion scan and CT pulmonary angiography, followed by effective anticoagulation and more aggressive measures such as thrombolysis as indicated, together with general supportive measures. Postpartum management should cover subsequent health issues, including breastfeeding, contraception, mood changes, and recurrence in subsequent pregnancies.
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Four Waves of the COVID-19 Pandemic: Comparison of Clinical and Pregnancy Outcomes. Viruses 2022; 14:v14122648. [PMID: 36560652 PMCID: PMC9783983 DOI: 10.3390/v14122648] [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: 10/29/2022] [Revised: 11/17/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
During the last two and a half years, clinical manifestations, disease severity, and pregnancy outcomes have differed among pregnant patients with SARS-CoV-2 infection. These changes were preceded by the presence of new variants of SARS-CoV-2, known in the literature as variants of concern. The aim of this study is to describe the differences between maternal clinical characteristics and perinatal outcomes among pregnant women with COVID-19 during four waves of the COVID-19 epidemic in Serbia. This retrospective study included a series of 192 pregnant patients who were hospitalized due to the severity of their clinical status of SARS-CoV-2 infection. During four outbreaks of COVID-19 infection in Serbia, we compared and analyzed three sets of variables, including signs, symptoms, and characteristics of COVID-19 infection, clinical endpoints, and maternal and newborn parameters. During the dominance of the Delta variant, the duration of hospitalization was the longest (10.67 ± 1.42 days), the frequency of stillbirths was the highest (17.4%), as well as the frequency of progression of COVID infection (28.9%) and the requirement for non-invasive oxygen support (37%). The dominance of the Delta variant was associated with the highest number of prescribed antibiotics (2.35 ± 0.28), the most common presence of nosocomial infections (21.7%), and the highest frequency of corticosteroid therapy use (34.8%). The observed differences during the dominance of four variants of concern are potential pathways for risk stratification and the establishment of timely and proper treatments for pregnant patients. Early identification of the Delta variant, and possibly some new variants with similar features in the future, should be a priority and, perhaps, even an opportunity to introduce more accurate and predictive clinical algorithms for pregnant patients.
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Hamel S, Ouellet S, Simard C, Robert A, Wou K, St-Georges S, Lam S, Bessissow A, Tagalakis V, Snell L, Malhamé I. Developing a Patient Information Tool for Pregnant People Requiring Diagnostic Imaging for Pulmonary Embolism: A Providers' Needs Assessment. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:1132-1133. [PMID: 35940356 DOI: 10.1016/j.jogc.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/21/2022] [Accepted: 07/26/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Sandrine Hamel
- Department of Medicine, McGill University Health Centre, Montréal, QC
| | - Suzie Ouellet
- Department of Medicine, McGill University Health Centre, Montréal, QC
| | - Camille Simard
- Department of Medicine, Jewish General Hospital, Montréal, QC
| | - Antony Robert
- Department of Emergency Medicine, McGill University Health Centre, McGill University, Montréal, QC
| | - Karen Wou
- Department of Obstetrics and Gynecology, McGill University Health Centre, McGill University, Montréal, QC
| | - Sarah St-Georges
- Department of Obstetrics and Gynecology, McGill University Health Centre, McGill University, Montréal, QC
| | - Stephanie Lam
- Department of Radiology, McGill University Health Centre, McGill University, Montréal, QC
| | - Amal Bessissow
- Department of Medicine, McGill University Health Centre, Montréal, QC
| | - Vicky Tagalakis
- Department of Medicine, Jewish General Hospital, Montréal, QC; Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, QC
| | - Linda Snell
- Department of Medicine, McGill University Health Centre, Montréal, QC; Institute of Health Sciences Education, McGill University, Montréal, QC
| | - Isabelle Malhamé
- Department of Medicine, McGill University Health Centre, Montréal, QC; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, QC.
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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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50
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Wu YY, Shan TT, Pan XT. Pulmonary Embolism After in vitro Fertilization and Cesarean Section: Two Case Reports and Brief Review of the Literature. Int J Womens Health 2022; 14:1489-1497. [PMID: 36317008 PMCID: PMC9617515 DOI: 10.2147/ijwh.s366355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 10/05/2022] [Indexed: 11/23/2022] Open
Abstract
This paper reports two cases of postpartum pulmonary embolism in Taicang First People's Hospital affiliated to Soochow University. They share many similarities in age, fertilization way, birthing method, incidence of pulmonary embolism, treatment and prognosis. The main purpose is to inspire the current maternal PTE risk assessment, diagnosis and treatment, as well as to explore the existing limitations and problems.
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Affiliation(s)
- Yu-Yan Wu
- Hematology Department, Taicang Hospital of Soochow University, Medical College of Soochow University, Taicang City, People’s Republic of China
| | - Tian-Tian Shan
- Hematology Department, Taicang Hospital of Soochow University, Medical College of Soochow University, Taicang City, People’s Republic of China
| | - Xiang-Tao Pan
- Hematology Department, Taicang Hospital of Soochow University, Medical College of Soochow University, Taicang City, People’s Republic of China,Correspondence: Xiang-Tao Pan, Hematology Department, Taicang hospital of Soochow University, Medical College of Soochow University, Taicang City, People’s Republic of China, Email
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