New cut-off point for D-dimer in the diagnosis of pulmonary embolism during pregnancy

Diagnostic value of D-dimer to fibrinogen ratio for pulmonary embolism in postpartum women

BACKGROUND

Pulmonary embolism is a common disease associated with high mortality and morbidity. Diagnosing pulmonary embolism is challenging due to diverse clinical presentations and the lack of specific biomarkers. The study aimed to investigate the diagnostic value on pulmonary embolism for postpartum women by D-dimer to fibrinogen ratio, and it combined with neutrophil-to-lymphocyte ratio or platelet-to-lymphocyte ratio.

METHODS

A total of 537 women with suspected pulmonary embolism were selected as the research subjects from the Shanghai First Maternity and Infant Hospital between 1 January 2019 and 31 October 2022. The D-dimer to fibrinogen ratio and it combined with neutrophil-to-lymphocyte ratio or platelet-to-lymphocyte ratio were applied to evaluate the clinical probability of pulmonary embolism, and the positive predictive value of both scores were calculated using computed tomography pulmonary arteriography as a gold standard. The diagnostic value of D-dimer to fibrinogen ratio, combined with neutrophil-to-lymphocyte ratio or platelet-to-lymphocyte ratio was evaluated by the area under the curve, sensitivity, specificity, and other indicators in the receiver operator characteristic curve.

RESULTS

Among the 502 women included for analysis, 194 (38.65%) were definitely diagnosed as pulmonary embolism. The positive predictive values of D-dimer to fibrinogen ratio and it combined with platelet-to-lymphocyte ratio or neutrophil-to-lymphocyte ratio were 70.1%, 50.5%, and 56.5%, respectively in the postpartum women, the area under the curve for the D-dimer to fibrinogen ratio and it combined with platelet-to-lymphocyte ratio or neutrophil-to-lymphocyte ratio were 0.606 (95%CI: 0.562-0.650), 0.624 (95%CI: 0.575-0.673), and 0.639 (95%CI: 0.592-0.686), respectively. The negative predictive values of D-dimer to fibrinogen ratio, it combined with platelet-to-lymphocyte ratio or neutrophil-to-lymphocyte ratio were 50.5%, 70.1%, and 69.8%, respectively.

CONCLUSION

The diagnostic value of the D-dimer to fibrinogen ratio was higher than the D-dimer for the postpartum women with suspected pulmonary embolism. The combination of either the neutrophil-to-lymphocyte ratio or the platelet-to-lymphocyte ratio with D-dimer to fibrinogen ratio is an appropriate strategy to rule out pulmonary embolism.

Pulmonary Embolism in Pregnancy: A Review for Clinical Practitioners

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.

Pregnancy-adapted YEARS Algorithm: A Retrospective Analysis

Introduction

Pulmonary embolism (PE) is an imperative diagnosis to make given its associated morbidity. There is no current consensus in the initial workup of pregnant patients suspected of a PE. Prospective studies have been conducted in Europe using a pregnancy-adapted YEARS algorithm, which showed safe reductions in computed tomography pulmonary angiography (CTPA) imaging in pregnant patients suspected of PE. Our objective in this study was 1) to measure the potential avoidance of CTPA use in pregnant patients if the pregnancy-adapted YEARS algorithm had been applied and 2) to serve as an external validation study of the use of this algorithm in the United States.

Methods

This study was a single-system retrospective chart analysis. Criteria for inclusion in the cohort consisted of keywords: pregnant; older than 18; chief complaints of shortness of breath, chest pain, tachycardia, hemoptysis, deep vein thromboembolism (DVT), and D-dimer-from January 1, 2019- May 31,2022. We then analyzed this cohort retrospectively using the pregnancy-adapted YEARS algorithm, which includes clinical signs of a DVT, hemoptysis, and PE as the most likely diagnosis with a D-dimer assay. Patients within the cohort were then subdivided into two categories: aligned with the YEARS algorithm, or not aligned with the YEARS algorithm. Patients who did not receive a CTPA were analyzed for a subsequent diagnosis of a PE or DVT within 30 days.

Results

A total of 74 pregnant patients were included in this study. There was a PE prevalence of 2.7% (two patients). Of the 36 patients who did not require imaging by the algorithm, seven CTPA were performed. Of the patients who did not receive an initial CTPA, zero were diagnosed with PE or DVT within a 30-day follow-up. In total, 85.1% of all the patients in this study were treated in concordance with the pregnancy-adapted YEARS algorithm.

Conclusion

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

Trajectories of maternal D-dimer are associated with the risk of developing adverse maternal and perinatal outcomes: a prospective birth cohort study

OBJECTIVE

To assess the relationships of maternal D-dimer trajectories with the risk of developing adverse maternal and perinatal outcomes (AMPOs).

METHODS

A prospective birth cohort study was conducted in China, and 7,095 women who had singleton birth were included. The latent class growth model was used to determine the maternal D-dimer trajectory.

RESULTS

Three maternal D-dimer trajectories were identified: (1) slight increase (43.6%), (2) rapid rise (51.3%), (3) sustained high (5.1%). Compared to pregnant women with a slight increase in D-dimer trajectory, the risk of gestational diabetes mellitus, placenta previa, macrosomia, large for gestational age (LGA), and increased postpartum bleeding was significantly increased in those with a rapid rise trajectory (adjusted OR=1.22, 2.00, 1.80, and 1.56, adjusted β=15.92∼25.1ml, respectively, P<0.05), and women with a sustained high trajectory also demonstrated a relatively elevated risk of macrosomia and LGA (adjusted OR=2.11 and 1.82, respectively, P<0.05). While the odds of pregnancy-induced hypertension, low birth weight, and small for gestational age in pregnant women with the rapid rise D-dimer trajectory and fetal distress in those with sustained high trajectory exhibited a reduction (adjusted OR=0.62, 0.38, 0.54, and 0.64, respectively, P<0.05).

CONCLUSION

This study highlights the influence of inappropriate maternal D-dimer trajectories on the risk of AMPOs.

Determining the diagnostic value of three clinical criteria Wells', YEARS and modified Geneva in pregnant women with suspected pulmonary thromboembolism

BACKGROUND

Diagnosis of pulmonary thromboembolism (PTE) during pregnancy is a challenging medical issue due to complications of X-ray-based imaging studies such as Ct-angiography for neonates and pregnant women. Here we aimed to assess the predictive values of three clinical criteria for diagnosing PTE during pregnancy.

METHODS

This is a retrospective cohort study performed in 2018-2020 on 166 pregnant women suspected of PTE. We reviewed the documents of all patients referred to our medical center with suspected symptoms of PTE. The demographic characteristics of the patients, signs and clinical findings upon the arrival of patients as well as their laboratory tests including D-dimer with a history of abortion or delivery and leg symptoms were entered into the data collection form. Then, according to the information extracted from the patient's files, each patient was evaluated by all clinical PTE criteria, including Wells, YEARS and modified Geneva. For each patient according to clinical criteria and all three algorithms, clinical suspicion for PTE and treatment or non-treatment was determined were compared to the final MDCT result of patients.

RESULTS

The Well's criteria had 100% sensitivity, 6.47% specificity, a positive predictive value of 7.8% and a negative predictive value of 100%. In patients with Well's score of more than four, the sensitivity and specificity of PTE diagnosis were 100% and 6% respectively. The modified Geneva criteria had 100% sensitivity, 8.89% specificity, a positive predictive value of 8.21% and a negative predictive value of 100%. The modified Geneva criteria had 100% sensitivity, 7.74% specificity, positive predictive value of 8.44% and a negative predictive value of 100%.

CONCLUSION

Wells, YEARS and modified Geneva criteria could significantly rule out PTE in pregnancy with 100% sensitivity.

[Clinical Confusion Concerning Increased D-Dimer Value during Pregnancy]

Plasma D-dimer, a special cross-linked fibrin derivative, is produced when fibrin is degraded by plasminase. During pregnancy, D-dimer increases along with the increase of gestational age, and the reference value of plasma D-dimer (≤0.5 mg/L) traditionally used for the screening of venous thrombosis in the normal population is not applicable to the pregnant population. Due to the lack of uniform D-dimer detection methods or measurement units, there is currently no unified D-dimer reference values for pregnancy or puerperium. Each region or laboratory should establish its own pregnancy D-dimer reference value for different gestational weeks through blood coagulation function testing of large numbers of samples of different gestational periods. More and more studies have been conducted to investigate the association between D-dimer and venous thromboembolism (VTE) during pregnancy, gestational hypertensive disorders (GHD) and pregnancy outcome. We reviewed, herein, the generation and measurement of D-dimer, the reference values of D-dimer during normal pregnancy, and the association between D-dimer and some pathological pregnancies, intending to help clinicians develop a more thorough understanding of D-dimer during pregnancy.