Diagnosis Of Pulmonary Embolism In Pregnancy Research Articles

Comparison of Guidelines for Evaluation of Suspected Pulmonary Embolism in Pregnancy: A Cost-effectiveness Analysis

Pulmonary embolism (PE) remains a leading cause of maternal mortality, yet diagnosis remains challenging. International diagnostic guidelines vary significantly in their recommendations, making it difficult to determine an optimal policy for evaluation. Which societal-level diagnostic guidelines for evaluation of suspected PE in pregnancy are an optimal policy in terms of its cost-effectiveness? We constructed a complex Markov decision model to evaluate the cost-effectiveness of each identified societal guidelines for diagnosis of PE in pregnancy. Our model accounted for risk stratification, empiric treatment, diagnostic testing strategies, as well as short- and long-term effects from PE, treatment with low-molecular-weight heparin, and radiation exposure from advanced imaging. We considered clinical and cost outcomes of each guideline from a US health care system perspective with a lifetime horizon. Clinical effectiveness and costs were measured in time-discounted quality-adjusted life years (QALYs) and US dollars, respectively. Strategies were compared using the incremental cost-effectiveness ratio (ICER) with a willingness-to-pay threshold of $100,000/QALY. One-way, multiway, and probabilistic sensitivity analyses were performed. We identified six international societal-level guidelines. Base-case analysis showed the guideline proposed by the American Thoracic Society and Society of Thoracic Radiology (ATS-STR) yielded the highest health benefits (22.90 QALYs) and was cost-effective, with an ICER of $7,808 over the guidelines proposed by the Australian Society of Thrombosis and Haemostasis and the Society of Obstetric Medicine of Australia and New Zealand (ASTH-SOMANZ). All remaining guidelines were dominated. The ATS-STR guideline-recommended strategy yielded an expected additional 2.7 QALYs/100 patients evaluated over the ASTH-SOMANZ. Conclusions were robust to sensitivity analyses, with the ATS-STR guidelines optimal in 86%of probabilistic sensitivity analysis scenarios. The ATS-STR guidelines for diagnosis of suspected PE in pregnancy are cost-effective and generate better expected health outcomes than guidelines proposed by other medical societies.

Diagnosing Pulmonary Embolism in Pregnancy: Synthesis of Current Guidelines and New Evidence.

Pulmonary embolism (PE) complicates 5.4 per 10 000 pregnancies and remains a significant cause of maternal mortality. Prompt diagnosis and treatment of PE are key to ensuring optimal outcomes, but are not without risks associated with over-testing. Given the paucity of evidence informing PE diagnosis in pregnancy, marked heterogeneity exists among different societies in their recommendations. Here we provide an overview of existing recommendations and novel evidence informing the diagnosis of PE in pregnancy, including the use of d-dimers, the choice of diagnostic imaging modality, and the potential for breast cancer risk among women exposed to ionizing radiation from computed tomography pulmonary angiography (CTPA).

Accuracy of PE rule-out strategies in pregnancy: secondary analysis of the DiPEP study prospective cohort

ObjectiveRecent studies suggest that combinations of clinical probability assessment (the YEARS algorithm or Geneva score) and D-dimer can safely rule out suspected pulmonary embolism (PE) in pregnant women. We performed...

New evidence in diagnosis of pulmonary embolism during pregnancy.

Diagnosis of pulmonary embolism (PE) in pregnancy is notoriously difficult and lacking high quality evidence. Three studies (DiPEP, ARTEMIS and CT-PE-Pregnancy) evaluating a systematic approach to PE diagnosis have recently been published. DiPEP is a retrospective case-control study that found a poor utility of clinical decision rules or D-dimer testing for PE diagnosis in pregnancy. ARTEMIS and CT-PE-Pregnancy are well conducted prospective management studies that proposed two algorithms with different clinical decision rules and D-dimer criteria for the diagnosis of PE in pregnancy. They included few events in high risk patients, which makes difficult the assessment of both algorithm's safety in women with a high probability of PE. Considering this new evidence, D-dimer testing might be useful to avoid radiation imaging in pregnant women considered at low risk for PE. In contrast, a negative D-dimer cannot be considered sufficiently safe to rule out PE when clinicians estimate that PE is the most likely diagnosis.

10 Decision analysis modelling of diagnostic strategies for suspected pulmonary embolism in pregnancy: the DiPEP economic evaluation

BackgroundUsing diagnostic imaging for suspected pulmonary embolism (PE) in pregnancy involves weighing the benefits, harms and costs of different approaches to selecting women for imaging.ObjectivesTo estimate the effectiveness of diagnostic...

19 Accuracy of biomarkers for venous thromboembolism in pregnancy: the diagnosis of pulmonary embolism in pregnancy (DiPEP) biomarker study

ObjectiveTo estimate the accuracy of biomarkers for venous thromboembolism (VTE) in pregnant and postpartum women with suspected pulmonary embolism (PE).DesignObservational cohort study augmented with additional cases with VTE.SettingEmergency departments and...

OC-8a: Diagnosis of pulmonary embolism in pregnancy (DiPEP)

OC-8a: Diagnosis of pulmonary embolism in pregnancy (DiPEP)

The utility of the Wells clinical prediction model and ventilation-perfusion scanning for pulmonary embolism diagnosis in pregnancy

Pulmonary embolism is one of the leading causes of mortality in pregnancy in the Western world. No clinical prediction models have been validated in pregnancy. As a result, any pregnant woman presenting with signs possibly consistent with pulmonary embolism is investigated radiologically. This study investigates whether using clinical prediction models for pulmonary embolism in pregnancy should be pursued in future prospective trials. The aim of this study was to retrospectively evaluate the Wells clinical prediction model and ventilation-perfusion scanning for pulmonary embolism in pregnancy. A retrospective study was performed on consecutive pregnant women who presented with suspected pulmonary emboli and underwent ventilation perfusion scanning at two tertiary institutions from 2007 until 2010. The clinical pretest probability was determined as likely or unlikely by two independent clinicians retrospectively using Wells-modified criteria. Scans were determined as normal, nondiagnostic or high probability for pulmonary emboli independently by two experienced radiologists. Disagreements were resolved by a third assessor independently. In 183 pregnant women, the pretest probability was determined as 'pulmonary emboli likely' in 76 (42%) and 'pulmonary emboli unlikely' in 107 (58%) of women. Scans were of high probability in four (2%), nondiagnostic in six (3%) and normal in 173 (95%) of women. This gives the pretest probability using Wells-modified criteria a sensitivity of 100% [95% confidence interval (CI) 0.4-1.0] and a negative predictive value of 100% (95% CI 0.96-1.0). A structured clinical model such as modified Wells criteria may be useful in pregnancy, but further prospective evaluation is required.

The Challenge of Diagnosing Pulmonary Embolism in Children, Pregnant Women, and Elderly Patients: A Descriptive Review of the Literature

The prompt and accurate diagnosis of pulmonary embolism (PE) greatly influences patient outcomes. However, diagnosing PE is one of the most difficult challenges confronting physicians, even more so when the clinical suspicion is addressed in children, during pregnancy, or in elderly patients. In these patient groups, symptoms and signs from concomitant conditions or diseases may mimic PE and make difficult defining clinical probability categories for PE as usually applied to general adult patients. Moreover, the diagnostic techniques show wider, specific limitations in these settings. PE is considered rare in children. The diagnostic management of a child with suspected PE is largely extrapolated from the knowledge achieved in adult patients. An increased risk of venous thromboembolism is reported in all trimesters of pregnancy and in the puerperium. An accurate diagnosis of PE in pregnancy has important implications, including the need for prolonged anticoagulation, delivery planning, and prophylaxis during future pregnancies, as well as concerns about future oral contraceptive use and estrogen therapy. Although incidence, morbidity, and mortality increase steadily with age, PE remains an underdiagnosed disease in elderly patients. About 40% of PE found at necropsy were not suspected antemortem. In the present article, challenges in diagnosing PE in children, during pregnancy, and in the elderly will be discussed, reviewing the available clinical, laboratory, and instrumental diagnostic strategies.

Outcomes of Negative Multidetector Computed Tomography with Pulmonary Angiography in Pregnant Women Suspected of Pulmonary Embolism

Validated clinical pretest probability tools are lacking in the diagnosis of pulmonary embolism (PE) in pregnancy, and the negative predictive value of D-dimers in this population has not been appropriately tested. The goal of this study was to evaluate outcomes of negative multidetector computed tomography with pulmonary angiography (MDCT-PA) for the diagnosis of PE in pregnancy in the absence of such measures. Imaging and medical record data, including clinical presentation, risk factors, and all imaging studies performed for the diagnosis of venous thromboembolism (VTE), of 343 pregnant women with PE were reviewed retrospectively. The imaging was performed at a large tertiary-care women's hospital between 2004 and 2008 using the same-generation MDCT scanner. Primary outcome measure was the occurrence of VTE events 3 months following MDCT-PA or 6 weeks postpartum (whichever came later). Dyspnea (75.6%) and chest pain (45.6%) were the most common complaints. Fifty-seven percent of patients had at least one additional risk factor other than pregnancy. Body mass index >30 was the most common risk factor (49%). Eight scans were positive for PE and one patient with a negative MDCT-PA had a positive upper-extremity ultrasound, yielding a diagnosis of VTE in 2.9%. Negative scans were technically adequate in 79.1%, technically limited in 20%, and inconclusive in 0.9%. Follow-up showed no symptomatic VTE events after index imaging. This study showed that MDCT-PA may safely exclude clinically significant PE in pregnancy.