Pulmonary embolism in pregnancy
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Background
- Incidence of VTE in pregnancy and postpartum is 1.72 per 1000[1]
- The risk is significantly elevated in the 6 wks postpartum
- Risk returns to baseline by 12 wks postpartumm[3]
- Consider MI in differential as risk can increase 3-6 times during the postpartum period
Clinical Spectrum of Venous thromboembolism
- Deep venous thrombosis (uncomplicated)
- Phlegmasia alba dolens
- Phlegmasia cerulea dolens
- Venous gangrene
- Pulmonary embolism
- Isolated distal deep venous thrombosis
Only 40% of ambulatory ED patients with PE have concomitant DVT[4][5]
Pulmonary Embolism Categorization[6]
Massive: High-risk
Hemodynamically unstable with symptoms of shock
- ACCP 2016 CHEST Guidelines: Sustained hypotension ONLY criteria (systolic BP <90 for at least 15min or requiring inotropic support)
- Previous definitions (e.g. AHA 2011) include cardiac arrest/pulselessness or persistent profound bradycardia (HR <40 with signs of shock)
Submassive: Intermediate-risk
Right ventricular dysfunction (RVD) and/or myocardial necrosis in the absence of persistent hypotension or shock (SBP >90)[7]
- RV dysfunction
- RV dilation or dysfunction on TTE
- "D Sign" on bedside echo (LV takes on a "D" shape due to RV dilation)
- RV dysfunction on CT defined as RV/LV ratio >0.9[8]
- Elevation of BNP (>90)
- ECG findings of right heart strain (see diagnosis below)
- RV dilation or dysfunction on TTE
- Myocardial necrosis: Troponin I >0.4
Non-Massive: Low-risk
No hemodynamic compromise and no RV strain
Sub-Segmental
- Limited to the subsegmental pulmonary arteries
Clinical Features
Symptoms
According to the PIOPED II study, these are the most common presenting signs[9]
- Dyspnea at rest or with exertion (73%)
- Pleuritic chest pain (44%)
- Cough (37%)
- Orthopnea (28%)
- Calf or thigh pain and/or swelling (44%)
- Wheezing (21%)
- Hemoptysis (13%)
Signs
- Tachypnea (54%)
- Calf or thigh swelling, erythema, edema, tenderness, palpable cord (47%)
- Tachycardia (24%)
- Rales (18%)
- Decreased breath sounds (17%)
- Accentuated pulmonic component of the second heart sound (15%)
- JVD (14%)
- Fever (3%)
Differential Diagnosis
Chest pain
Critical
- Acute coronary syndromes (ACS)
- Aortic dissection
- Cardiac tamponade
- Coronary artery dissection
- Esophageal perforation (Boerhhaave's syndrome)
- Pulmonary embolism
- Tension pneumothorax
Emergent
- Cholecystitis
- Cocaine-associated chest pain
- Mediastinitis
- Myocardial rupture
- Myocarditis
- Pancreatitis
- Pericarditis
- Pneumothorax
Nonemergent
- Aortic stenosis
- Arthritis
- Asthma exacerbation
- Biliary colic
- Costochondritis
- Esophageal spasm
- Gastroesophageal reflux disease
- Herpes zoster / Postherpetic Neuralgia
- Hypertrophic cardiomyopathy
- Hyperventilation
- Mitral valve prolapse
- Panic attack
- Peptic ulcer disease
- Pleuritis
- Pneumomediastinum
- Pneumonia
- Rib fracture
- Stable angina
- Thoracic outlet syndrome
- Valvular heart disease
- Muscle sprain
- Psychologic / Somatic Chest Pain
- Spinal Root Compression
- Tumor
Evaluation
Clinical Decision Rules
- Limited utility as no studies (PERC, Wells) have proven effective in pregnancy
If clinical features suggestive of PE and lower extremity swelling then:
- Bilateral LE Ultrasound
- Up to 17% of pregnant patients have isolated pelvic DVT(not found with ultrasound)[14]
- CT (with shield) vs. V/Q is roughly equilivalent radiation exposure
{{Guidelines PE Pregnancy}}
D-Dimer
- D-Dimer MAY BE used with following limits with very poor evidence[15][16][17]
- 1st trimester: <750 ng/mL (+50% increase from normal lab threshold)
- 2nd trimester: <1000 ng/mL (+100% from normal)
- 3rd trimester: <1250 ng/mL (+150% from normal)
Management
- Heparin and Enoxaparin are safe (coumadin is not)
- Perimortem cesarean delivery with cardiac arrest with no ROSC in 5 min
- Consider thrombolysis in severely unstable post-partum pulmonary embolism[19](see Adult pulseless arrest for tPA dosing in pulmonary embolism)
Disposition
- Admit
See Also
References
- ↑ James AH, et al. Venous thromboembolism during pregnancy and the postpartum period: Incidence, risk factors, and mortality. 2006; 194(5):1311–1315.
- ↑ 2.0 2.1 Chan et al. Venous Thromboembolism and Antithrombotic Therapy in Pregnancy. SOGC Guidelines. 2014.
- ↑ Kamel H, et al. Risk of a thrombotic event after the 6-week postpartum period. N Engl J Med. 2014; 370:1307-1315.
- ↑ Righini M, Le GG, Aujesky D, et al. Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. Lancet. 2008; 371(9621):1343-1352.
- ↑ Daniel KR, Jackson RE, Kline JA. Utility of the lower extremity venous ultrasound in the diagnosis and exclusion of pulmonary embolism in outpatients. Ann Emerg Med. 2000; 35(6):547-554.
- ↑ Jaff MR et al. Management of massive and submassive pulmonary embolism, ileofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011 Apr 26;123(16):1788-830. doi: 10.1161/CIR.0b013e318214914f. Epub 2011 Mar 21
- ↑ Martin C et al. Systemic thrombolysis for pulmonary embolism: a review. P T. 2016 Dec; 41(12):770-775
- ↑ Becattini C et al. Multidetector computed tomography for acute pulmonary embolism: diagnosis and risk stratification in a single test. Eur Heart J. 2011 Jul;32(13):1657-63. doi: 10.1093/eurheartj/ehr108. Epub 2011 Apr 18.
- ↑ Stein PD et al. Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. Am J Med. 2007;120(10):871.
- ↑ Kline JA, et al. Clinical Features of Patients With Pulmonary Embolism and a Negative PERC Rule Result. Ann Emerg Med. 2013 January 60(1): 122-124
- ↑ West, J. “When the PERC Rule Fails”. ALiEM. Feb 2014[1]
- ↑ Astani SA, et al. Detection of pulmonary embolism during pregnancy: comparing radiation doses of CTPA and pulmonary scintigraphy. Nucl Med Commun. 2014; 35(7):704-711.
- ↑ Bentur Y, Horlatsch N, and Koren G. Exposure to ionizing radiation during pregnancy: perception of teratogenic risk and outcome. Teratology. 1991; 43(2):109-112.
- ↑ Chan WS, Spencer FA, Ginsberg JS. Anatomic distribution of deep vein thrombosis in pregnancy. CMAJ. 2010; 182(7):657- 660.
- ↑ Kovac M. The use of D-dimer with new cutoff can be useful in diagnosis of venous thromboembolism in pregnancy. Eur J Obstet Gynecol Reprod Biol. 2010 Jan;148(1):27-30
- ↑ http://blog.ercast.org/2013/04/pulmonary-embolism-in-pregnancy/
- ↑ D-Dimer Concentrations in Normal Pregnancy: New Diagnostic Thresholds Are Needed. Kline et all. Clinical Chemistry May 2005 vol. 51 no. 5 825-829 http://www.clinchem.org/content/51/5/825.long
- ↑ 18.0 18.1 Tintinalli's 7th edition
- ↑ Stone SE and Morris TA. Pulmonary embolism during and after pregnancy. (Crit Care Med 2005; 33[Suppl.]:S294 –S300.