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

Righini, Marc; Robert-Ebadi, Helia; Elias, Antoine; Sanchez, Olivier; Le Moigne, Emmanuelle; Schmidt, Jeannot; Le Gall, Catherine; Cornuz, Jacques; Aujesky, Drahomir; Roy, Pierre-Marie; Chauleur, Céline; Rutschmann, Olivier T; Poletti, Pierre-Alexandre; Le Gal, Grégoire (2018). Diagnosis of Pulmonary Embolism During Pregnancy: A Multicenter Prospective Management Outcome Study. Annals of internal medicine, 169(11), pp. 766-773. American College of Physicians 10.7326/M18-1670

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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 ultrasonography [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.

Item Type:

Journal Article (Original Article)

Division/Institute:

04 Faculty of Medicine > Department of General Internal Medicine (DAIM) > Clinic of General Internal Medicine

UniBE Contributor:

Aujesky, Drahomir

Subjects:

600 Technology > 610 Medicine & health

ISSN:

0003-4819

Publisher:

American College of Physicians

Language:

English

Submitter:

Christine Baumgartner

Date Deposited:

18 Jan 2019 11:18

Last Modified:

02 Dec 2019 17:58

Publisher DOI:

10.7326/M18-1670

PubMed ID:

30357273

BORIS DOI:

10.7892/boris.123193

URI:

https://boris.unibe.ch/id/eprint/123193

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