An Official American Thoracic Society/Society of Thoracic Radiology Clinical Practice Guideline: Evaluation of Suspected Pulmonary Embolism In Pregnancy

Leung, Ann N.; Bull, Todd; Jaeschke, Roman; Lockwood, Charles J.; Boiselle, Phillip M.; Hurwitz, Lynne M.; James, Andra H.; McCullough, Laurence B.; Menda, Yusuf; Paidas, Michael J.; Royal, Henry D.; Tapson, Victor F.; Winer-Muram, Helen T.; Chervenak, Frank A.; Cody, Dianna D.; McNitt‐Gray, Michael F.; Stave, Christopher D; Tuttle, Brandi

doi:10.1164/rccm.201108-1575st

Cited by 189 publications

(142 citation statements)

References 62 publications

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“…However, shortness of breath, tachycardia and leg oedema are not uncommon in normal pregnancy. Thus, VTE is confi rmed in less than 10 % of pregnant women with symptoms suggestive of PE or DVT [49].…”

Section: Clinical Presentationmentioning

confidence: 99%

“…It must be emphasised that, to date, there have been no randomised trials or even prospective studies that have set reference standards for the diagnosis of VTE in pregnant women [49]. In particular, clinical decision rules in pregnant women with suspected VTE have not yet been developed or prospectively validated.…”

Section: Diagnostic Workup -General Considerationsmentioning

confidence: 99%

“…A chest radiograph can be considered as fi rst imaging study, particularly in cases in which other diff erential diagnoses (e.g., pneumonia or pneumothorax) are at least as likely as PE [49,75,76]. The classic radiographic signs of PE -a peripheral wedge-shaped infi ltrate (Hampton's hump) and decreased pulmonary vascularity (Westermark's sign) -are rare fi ndings.…”

Section: Lung Scintigraphy or Ct Scanmentioning

confidence: 99%

“…Two studies including 105 and 24 pregnant women with suspected PE reported defi nite diagnostic scans in 94 % and 96 % of cases with normal initial chest radiography, respectively [80,82]. Regarding CTPA, the hyperdynamic eff ects of pregnancy, which include increases in cardiac output, vascular resistance, heart rate and plasma volume, can lead to a dilution of contrast agent and possibly to an interruption of the contrast bolus when opacifi ed blood from the superior vena cava is mixed with unopacifi ed blood from the IVC, which can result in poor opacifi cation of the pulmonary arteries [49,80,81,83]. Furthermore, pressure in the IVC is increased by the gravid uterus, especially in the supine position, and there is a signifi cant increase in IVC blood fl ow during deep inhalation.…”

Section: Lung Scintigraphy or Ct Scanmentioning

confidence: 99%

“…Technically inadequate and therefore non-diagnostic CTPA examinations have been reported in 6-36 % of cases [80, 84 -86]. Therefore, CTPA protocols must consider the haemodynamic changes that occur during pregnancy and should be adapted to improve image quality (e.g., avoidance of initial deep inhalation, automated bolus tracking, a short scan delay, high iodine fl ux achieved by high fl ow rate of contrast medium and/or high iodine concentration) [49,83]. In addition, adequate low-dose strategies for both lung scintigraphy and CTPA should be used while maintaining diagnostic quality [49].…”

Section: Lung Scintigraphy or Ct Scanmentioning

confidence: 99%

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Diagnosis of pregnancy-associated venous thromboembolism - position paper of the Working Group in Women’s Health of the Society of Thrombosis and Haemostasis (GTH)

Linnemann¹,

Scholz

Rott

et al. 2016

Vasa

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EpidemiologyVTE is a leading cause of maternal morbidity in the developed world and, in the case of PE, of mortality as well [1]. While the relative risk of VTE is greatly increased during pregnancy compared with that in non-pregnant women, the absolute risk remains low: estimates of the incidence of pregnancy-associated VTE have varied from 1:500 to 1:1500 pregnancies [2 -7]. The risk of VTE is approximately 5-fold greater in pregnant women than in non-pregnant women.Approximately 80 % of pregnancy-associated VTEs are isolated DVTs, and approximately 20 % are PEs or both DVTs and PEs [5]. Although a systematic review reported weighted event rates for DVT of 21.9 %, 33.7 % and 47.6 % for the fi rst, second and third trimesters, respectively [6], a recent study suggested that the risk might in fact increase exponentially over the duration of the pregnancy [7], with 12.4 % of VTEs diagnosed in the fi rst trimester, 15.3 % in the second trimester and 72.3 % in the third trimester. This detailed risk assessment for each gestational week demonstrated a 21-fold increased risk for the last two weeks before delivery [7]. Summary: Pregnancy and the postpartum period are associated with an increased risk of venous thromboembolism (VTE). Over the past decade, new diagnostic algorithms have been established, combining clinical probability, laboratory testing and imaging studies for the diagnosis of deep vein thrombosis (DVT) and pulmonary embolism (PE) in the non-pregnant population. However, there is no such generally accepted algorithm for the diagnosis of pregnancy-associated VTE. Studies establishing clinical prediction rules have excluded pregnant women, and prediction scores currently in use have not been prospectively validated in pregnancy or during the postpartum period. D-dimers physiologically increase throughout pregnancy and peak at delivery, so a negative D-dimer test result, based on the reference values of non-pregnant subjects, becomes unlikely in the second and third trimesters. Imaging studies therefore play a major role in confi rming suspected DVT or PE in pregnant women. Major concerns have been raised against radiologic imaging because of foetal radiation exposure, and doubts about the diagnostic value of ultrasound techniques in attempting to exclude isolated iliac vein thrombosis grow stronger as pregnancy progresses. As members of the Working Group in Women's Health of the Society of Thrombosis and Haemostasis (GTH), we summarise evidence from the available literature and aim to establish a more uniform strategy for diagnosing pregnancy-associated VTE. Review Diagnosis of pregnancy-associated

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Section: Clinical Presentationmentioning

confidence: 99%

Section: Diagnostic Workup -General Considerationsmentioning

confidence: 99%

Section: Lung Scintigraphy or Ct Scanmentioning

confidence: 99%

Section: Lung Scintigraphy or Ct Scanmentioning

confidence: 99%

Section: Lung Scintigraphy or Ct Scanmentioning

confidence: 99%

See 3 more Smart Citations

Diagnosis of pregnancy-associated venous thromboembolism - position paper of the Working Group in Women’s Health of the Society of Thrombosis and Haemostasis (GTH)

Linnemann¹,

Scholz

Rott

et al. 2016

Vasa

View full text Add to dashboard Cite

show abstract

Review of Pulmonary Embolism

Vinson

Sperling

Roubinian

2023

JAMA

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Trends in Medical Imaging During Pregnancy in the United States and Ontario, Canada, 1996 to 2016

et al. 2019

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IMPORTANCE The use of medical imaging has sharply increased over the last 2 decades. Imaging rates during pregnancy have not been quantified in a large, multisite study setting. OBJECTIVE To evaluate patterns of medical imaging during pregnancy. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was performed at 6 US integrated health care systems and in Ontario, Canada. Participants included pregnant women who gave birth to a live neonate of at least 24 weeks' gestation between January 1, 1996, and December 31, 2016, and who were enrolled in the health care system for the entire pregnancy. EXPOSURES Computed tomography (CT), magnetic resonance imaging, conventional radiography, angiography and fluoroscopy, and nuclear medicine. MAIN OUTCOMES AND MEASURES Imaging rates per pregnancy stratified by country and year of child's birth. RESULTS A total of 3 497 603 pregnancies in 2 211 789 women were included. Overall, 26% of pregnancies were from US sites. Most (92%) were in women aged 20 to 39 years, and 85% resulted in full-term births. Computed tomography imaging rates in the United States increased from 2.0 examinations/1000 pregnancies in 1996 to 11.4/1000 pregnancies in 2007, remained stable through 2010, and decreased to 9.3/1000 pregnancies by 2016, for an overall increase of 3.7-fold. Computed tomography rates in Ontario, Canada, increased more gradually by 2.0-fold, from 2.0/1000 pregnancies in 1996 to 6.2/1000 pregnancies in 2016, which was 33% lower than in the United States. Overall, 5.3% of pregnant women in US sites and 3.6% in Ontario underwent imaging with ionizing radiation, and 0.8% of women at US sites and 0.4% in Ontario underwent CT. Magnetic

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An Official American Thoracic Society/Society of Thoracic Radiology Clinical Practice Guideline: Evaluation of Suspected Pulmonary Embolism In Pregnancy

Abstract: The recommendations presented in this guideline are based upon the currently available evidence; availability of new clinical research data and development and dissemination of new technologies will necessitate a revision and update.

Cited by 189 publications

References 62 publications

Diagnosis of pregnancy-associated venous thromboembolism - position paper of the Working Group in Women’s Health of the Society of Thrombosis and Haemostasis (GTH)

Diagnosis of pregnancy-associated venous thromboembolism - position paper of the Working Group in Women’s Health of the Society of Thrombosis and Haemostasis (GTH)

Review of Pulmonary Embolism

Trends in Medical Imaging During Pregnancy in the United States and Ontario, Canada, 1996 to 2016

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