Limitations of helical CT for the diagnosis of pulmonary thromboembolism during pregnancy and the puerperium

Abstract

THROMBOEMBOLISM DURING PREGNANCY AND THE PUERPERIUM FRANCIS NUTHALAPATY, MONIQUE HO, SATINDER SINGH, HRUDAYA NATH, JOHN OWEN, JOHN HAUTH, University of Alabama at Birmingham, Obstetrics & Gynecology, Birmingham, Alabama, University of Alabama at Birmingham, Radiology, Birmingham, Alabama OBJECTIVE: To determine the diagnostic outcomes of patients evaluated for pregnancy-associated pulmonary thromboembolism (PTE) using Helical Computed Tomography (HCT). STUDY DESIGN: We retrospectively reviewed the medical records of all women who underwent HCT between January 1, 1999 and March 31, 2004 for evaluation of possible pregnancy-associated PTE. Subjects were identified from hospital discharge and radiology procedure records. Patient characteristics and diagnostic test outcomes were abstracted. RESULTS: Our case series consisted of 68 gravidas, with a mean age of 27 G 7 years, of whom 49% (33/68) underwent antenatal evaluation at a mean gestational age of 30 G 7 weeks. Postpartum evaluation occurred in 51% (35/ 68) of the cohort, of whom 37% delivered vaginally and 63% by cesarean. Sixtythree percent (43/68) of the HCT studies were interpreted as negative, 15% (10/ 68) as positive, and 22% (15/68) as indeterminate for PTE. Regardless of the HCT-PTE interpretation, 45% of all HCT reports included a qualifier that the study was either inadequate for interpretation (n = 3), or technically limited/ suboptimal (n = 27) due to poor contrast infusion, motion artifact, or large body habitus. Important additional pulmonary findings including pneumonia, effusions, and edema, were noted in 74% (50/68) of all HCT studies. Confirmatory pulmonary angiography (PA) was requested in 6 women who had compelling clinical evidence of PTE. Three had strong HCT support for PTE and anticoagulation, while 3 had either an indeterminant or negative study. All 6 women had normal PA. No apparent false negative tests occurred. CONCLUSION: The diagnosis of PTE during pregnancy and the peurperium using HCT is associated with an appreciable incidence of quality limiting factors and a worrisome positive predictive value. Our findings suggest that when HCT results indicate PTE, a definitive diagnostic evaluation (pulmonary arteriogram) should be performed prior to instituting long-term anticoagulation. 293 IS THERE A DIFFERENCE IN OBSTETRICAL OUTCOME BETWEEN MILD AND SEVERE RENAL DISEASE? ALISA MODENA, MATTHEW HOFFMAN, JORGE TOLOSA, Thomas Jefferson University, Department of Obstetrics and Gynecology, Philadelphia, Pennsylvania, Christiana Hospital, Newark, Delaware OBJECTIVE: An initial serum creatinine (SC) of greater or less than 1.4 mg/dL differentiates severe chronic renal disease (CRD) from mild. Perinatal outcome is considered to be significantly worse in severe CRD. Our objective is to determine if this concept remains accurate with current clinical management of these patients during pregnancy. STUDY DESIGN: We conducted a retrospective population based study at two institutions from 1990-2002. ICD-9 codes identified pregnancies complicated by chronic renal disease. A retrospective review of charts was undertaken. Data was analyzed with SPSS. RESULTS: There were 82 patients with chronic renal disease, SC range 0.411.3 mg/dL, of these 46 (57%) had severe CRD and 35 (43%) had mild CRD. The cause of CRD was: 49 (60%) chronic hypertension, 23 (28%) diabetes mellitus, 17 (20%) lupus, 6 (7%) membrano-proliferative glomerulonephritis, 4 (5%) polycystic kidney disease, 3 (4%) Post-streptococcal GN, 3 (4%) focal glomerulosclerosis, 2 (3%) sickle cell disease, 1 (1%) IgA nephropathy, 18 (22%) other causes. 16/82 (20%) patients had at least one renal transplant, and 11/82 (14%) were on dialysis during their pregnancy. There was no difference between the two groups in rates of preeclampsia (OR 0.66 CI .26-1.7, P =.55), IUGR (0.45, CI .09-2.1, P = .57) or neonatal mortality (OR 1.9, CI .5-7.4, P = .56). Patients with mild CRD delivered at a mean gestational age 33.6, those with severe CRD delivered at a mean gestational age of 31.4 (OR 2.7, CI .9-8, P = .11). CONCLUSION: There is no significant increased risk of adverse perinatal outcome in women with severe CRD compared to women with mild disease. A reevaluation of prognosis in these patients is warranted.