Pulmonary Embolism and Diagnostic CT in Pregnancy

Few studies have evaluated the use of
clinical decision rules or D-dimer to diagnose pulmonary embolism in pregnancy.
The YEARS criteria are used to evaluate suspected pulmonary embolism they
include three criteria to assess risk: clinical science or symptoms of DVT,
hemoptysis, and pulmonary embolism as the most likely diagnosis on the basis of
these criteria and their D-dimer result patients may then undergo CT pulmonary
angiography. In this multicenter International Management study, 498
consecutive pregnant patients with suspected pulmonary embolism, were
assessed for D-dimer concentration and the YEARS criteria. Patients who met
none of the criteria and had a D-dimer concentration of less than 1000
nanograms per milliliter, or with one or more criteria and a D-dimer
concentration of less than 500 nanograms per milliliter, were considered not to
have pulmonary embolism. Of the remaining patients in those with clinical signs of
DVT, the YEARS criteria were adjusted for
pregnancy to include compression ultrasound for DVT. In the absence of
clinical signs of DVT, or a negative ultrasound, CT pulmonary angiography was
performed. The primary outcome was the incidence of venous thromboembolism in
patients with initially normal tests during three months of follow-up. The key
secondary outcome was the percentage of patients in whom CT pulmonary
angiography was not indicated. With this approach the primary outcome occurred in
one patient who was diagnosed with popliteal DVT. No patient was diagnosed
with pulmonary embolism. 39 percent of the patients were managed without CT
angiography. Among the subgroup of women in the third trimester, 32% were managed
without CT angiography. The authors conclude that the use of the pregnancy
adapted YEARS algorithm safely ruled out acute pulmonary embolism in pregnant
patients referred for suspected pulmonary embolus. Full study results are
available at NEJM.org.

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