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Ann Intern Med. 2018 Oct 23. doi: 10.7326/M18-1670. [Epub ahead of print]

Diagnosis of Pulmonary Embolism During Pregnancy: A Multicenter Prospective Management Outcome Study.

Author information

1
Geneva University Hospitals, Geneva, Switzerland (M.R., H.R., O.T.R., P.P.).
2
Centre Hospitalier de Toulon, Toulon, France (A.E.).
3
Université Paris Descartes, Sorbonne Paris Cité, and Hôpital Européen Georges Pompidou, Paris, France (O.S.).
4
INSERM UMR S 1140, Paris, France, F-CRIN INNOVTE, Saint-Etienne, France, and Université de Brest, Brest, France (E.L.).
5
Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France (J.S.).
6
Centre Hospitalier d'Argenteuil, Argenteuil, France (C.L.).
7
Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (J.C.).
8
Bern University Hospital, University of Bern, Bern, Switzerland (D.A.).
9
University Hospital of Angers, Angers, France (P.R.).
10
INSERM U1059, University of Lyon, and University Hospital, Saint-Etienne, France (C.C.).
11
Université de Brest, Brest, France, and Ottawa Health Research Institute, Ottawa, Ontario, Canada (G.L.).

Abstract

Background:

Data on the optimal diagnostic management of pregnant women with suspected pulmonary embolism (PE) are limited, and guidelines provide inconsistent recommendations on use of diagnostic tests.

Objective:

To prospectively validate a diagnostic strategy in pregnant women with suspected PE.

Design:

Multicenter, multinational, prospective diagnostic management outcome study involving pretest clinical probability assessment, high-sensitivity D-dimer testing, bilateral lower limb compression ultrasonography (CUS), and computed tomography pulmonary angiography (CTPA). (ClinicalTrials.gov: NCT00740454).

Setting:

11 centers in France and Switzerland between August 2008 and July 2016.

Patients:

Pregnant women with clinically suspected PE in emergency departments.

Intervention:

Pulmonary embolism was excluded in patients with a low or intermediate pretest clinical probability and a negative D-dimer result. All others underwent lower limb CUS and, if results were negative, CTPA. A ventilation-perfusion (V/Q) scan was done if CTPA results were inconclusive. Pulmonary embolism was excluded if results of the diagnostic work-up were negative, and untreated pregnant women had clinical follow-up at 3 months.

Measurements:

The primary outcome was the rate of adjudicated venous thromboembolic events during the 3-month follow-up.

Results:

441 women were assessed for eligibility, and 395 were included in the study. Among these, PE was diagnosed in 28 (7.1%) (proximal deep venous thrombosis found on ultrasound [n = 7], positive CTPA result [n = 19], and high-probability V/Q scan [n = 2]) and excluded in 367 (clinical probability and negative D-dimer result [n = 46], negative CTPA result [n = 290], normal or low-probability V/Q scan [n = 17], and other reason [n = 14]). Twenty-two women received extended anticoagulation during follow-up, mainly for previous venous thromboembolic disease. The rate of symptomatic venous thromboembolic events was 0.0% (95% CI, 0.0% to 1.0%) among untreated women after exclusion of PE on the basis of negative results on the diagnostic work-up.

Limitation:

There were several protocol deviations, reflecting the difficulty of performing studies in pregnant women with suspected PE.

Conclusion:

A diagnostic strategy based on assessment of clinical probability, D-dimer measurement, CUS, and CTPA can safely rule out PE in pregnant women.

Primary Funding Source:

Swiss National Foundation for Scientific Research, Groupe d'Etude de la Thrombose de Bretagne Occidentale, and International Society on Thrombosis and Haemostasis.

PMID:
30357273
DOI:
10.7326/M18-1670

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