Diagnosis of Pulmonary Embolism in Pregnancy

Jack Fitzsimmons; Laura Hart; Emily Oliver; Wadia Mulla

doi:10.1055/a-2112-8049

American Journal of Perinatology, Table of Contents

Am J Perinatol 2024; 41(S 01): e2307-e2312
DOI: 10.1055/a-2112-8049

Clinical Opinion

Diagnosis of Pulmonary Embolism in Pregnancy

Authors

Jack Fitzsimmons

¹Department of Obstetrics, Gynecology and Reproductive Sciences, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
Laura Hart

¹Department of Obstetrics, Gynecology and Reproductive Sciences, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
Emily Oliver

¹Department of Obstetrics, Gynecology and Reproductive Sciences, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
Wadia Mulla

²Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania

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.

Keywords

pulmonary embolism - venous thromboembolism - computed tomography pulmonary angiography

Full Text

References

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