Clinical assessment and investigation of thrombotic disease in pregnancy

Abstract

Background Pulmonary embolism (PE) is a leading cause of maternal death. While many normal symptoms of pregnancy mimic those of venous thromboembolism (VTE), making diagnosis difficult, management of possible VTE in pregnant and postpartum women is further complicated by the potential risks of investigations. The management was therefore assessed against local guidelines. Methods 90 women who underwent investigation for VTE between January 2008 and May 2010 were identified from the Radiology database. The notes were analysed against the local management of suspected VTE in pregnancy guidelines. Results In this cohort, 5/90 (6%) investigations were positive (1 deep vein thrombosis), four PE). Most women presented with symptoms suggestive of PE and were referred via obstetric services or accident and emergency; there was poor adherence to guidelines via both routes. In particular the choice of scan (V/Q or CTPA) was incorrect in 25.4%. Women seen via obstetrics were more likely to have senior review (39% vs 8%, p<0.05 Fisher's exact test), less likely to have D-dimer (13% vs 37%, p<0.05) and more likely to be admitted (69% vs 31%, NS). Overall VTE Risk Assessment was poor (8%), as was documentation concerning risks of scans (44%). Conclusion Improvements in the management of suspected VTE are required. Guidelines were poorly followed and a large number of negative scans, with an associated radiation risk to mother and fetus, were undertaken. The development of pre-test probability scores may help rationalise those women who require scans, thereby reducing unnecessary hospital admission and/or radiation.

Systematic Review and Meta‐analysis of Pregnant Patients Investigated for Suspected Pulmonary Embolism in the Emergency Department

“…Two readers had perfect agreement on their choices of 17 retained full‐length papers and two abstracts (Table ). All 17 full‐length papers studied unselected emergency patients with suspected PE, including nonpregnant and pregnant patients, whereas both abstracts included only pregnant patients, and their results are included in the sensitivity analysis …”

“…3) The five non‐US full‐length studies included 6,767 patients with a pooled proportion of pregnant patients of 1.5% (95% CI = 0.9% to 2.3%; I² = 70%), a pooled rate of VTE+ diagnosis of 8.2% (95% CI = 1.5% to 29.7%; I² = 97%), and a pooled random‐effects RR of 0.61 (95% CI = 0.27 to 1.39; I² = 57%) . 4) Inclusion of the two abstracts of exclusively pregnant patients ( n = 239), which were both performed in Europe in the nonultrasound analysis, resulted in a RR of 0.36 (95% CI = 0.13 to 0.99) …”