Pulmonary embolism in pregnancy
Revision as of 14:50, 22 May 2015 by Neil.m.young (talk | contribs) (unclear comments of DVT prev. Ref added for pelvic DVT, couldn't find 10% number with lit search)
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]
Clinical Spectrum of Venous Thromboembolism
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]
Types
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
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
Diagnosis
- If clinical features suggestive of PE and lower extremity swelling then
- Bilateral LE Ultrasound
- if Positive-->treat empirically for PE
- if Negative-->CTA
- Up to 17% of pregnant patients have isolated pelvic DVT (not found with ultrasound)[10]
- CT (with shield) vs. V/Q is roughly equilivalent radiation exposure
American Thoracic Society In Pregnancy[11]
- D-dimer is not recommended for excluding PE (weak recommendation, very-low-quality evidence).
- If signs and symptoms of deep venous thrombosis (DVT), first perform bilateral venous compression ultrasound (CUS) of lower extremities, followed by anticoagulation treatment if positive and by further testing if negative (weak recommendation, very-low-quality evidence).
- If no signs and symptoms of DVT, pulmonary vascular imaging should be used over bilateral lower extremity ultrasounds(weak recommendation, very-low-quality evidence).
D-Dimer
- D-Dimer MAY BE used with following limits with very poor evidence[12][13][14]
- 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)
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.
- ↑ Chan WS, Spencer FA, Ginsberg JS. Anatomic distribution of deep vein thrombosis in pregnancy. CMAJ. 2010; 182(7):657- 660.
- ↑ Leung, A et al. An Official American Thoracic Society/Society of Thoracic Radiology Clinical Practice Guideline: Evaluation of Suspected Pulmonary Embolism PDF
- ↑ 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
- ↑ 15.0 15.1 Tintinalli's 7th edition