Computed tomography pulmonary angiography <i>versus</i> ventilation-perfusion lung scanning for diagnosing pulmonary embolism during pregnancy: a systematic review and meta-analysis

Tromeur, Cécile; Pol, Liselotte M. van der; Roux, Pierre‐Yves Le; Ende-Verhaar, Yvonne M.; Salaun, Pierre–Yves; Leroyer, Christophe; Couturaud, Francis; Kroft, Lucia J.M.; Huisman, Menno V.; Klok, Frederikus A.

doi:10.3324/haematol.2018.196121

Cited by 69 publications

(104 citation statements)

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“…Both pulmonary CTA and pulmonary ventilationperfusion scan can safely rule out PTE during pregnancy (8). Although pulmonary ventilation-perfusion scanning exposes the mother to lower doses of radiation compared to CT scan, the probability of non-diagnostic findings is higher than pulmonary CTA, which necessitates further imaging studies (8,9).…”

Section: Discussionmentioning

confidence: 99%

“…In addition, clinical prediction rules, which are used for pretest probability assessment of PTE, are not applicable during pregnancy (1). Use of imaging modali-ties during pregnancy is also challenging, especially in the early phase, due to the possible adverse effects on the fetus and the mother (8,9). Accordingly, practitioners sometimes rely on only clinical manifestations to manage pregnant women suspected of PTE, resulting in over-diagnosis or under-diagnosis of this condition.…”

Section: Introductionmentioning

confidence: 99%

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Evaluation of Pregnant Patients with Suspected Pulmonary Embolism: A Descriptive Cross-Sectional Study

et al. 2020

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Background: Pulmonary thromboembolism (PTE) is a leading cause of maternal mortality. However, diagnosis of PTE can be challenging during pregnancy, and there is no consensus regarding the best diagnostic approach. Objectives: The current study aimed to evaluate the applicability of clinical symptoms and diagnostic tests in ruling in or ruling out PTE during pregnancy. Methods: In this one-year, cross-sectional, descriptive study, we evaluated pregnant or postpartum (six weeks postpartum) women suspected of PTE, who were admitted to the internal medicine intensive care units (ICUs) of hospitals (Namazi and Shahid Faghihi hospitals), affiliated with Shiraz University, Shiraz, Iran, during August 2016-July 2017. The participants underwent electrocardiography (ECG), serum troponin-I and D-dimer measurements, chest X-ray, color-doppler sonography (CDS) of the lower extremity venous system, transthoracic echocardiography, pulmonary perfusion scan, or pulmonary computed tomography angiography (CTA). The participants’ clinical manifestations were also assessed. Results: A total of 103 women, with the mean age of 30.37 ± 5.35 years, were included in this study. Seventy-seven women underwent pulmonary CTA or pulmonary perfusion scan. PTE was documented in nine cases. Dyspnea was the most common symptom. The respiratory rate, cough, dizziness, and fever on admission had significant correlations with the final diagnosis of PTE (P = 0.01, 0.03, 0.007, and 0.04, respectively). The ECG study of one case with PTE showed right axis deviation, while the ECG findings of the other eight cases showed no specific pattern. The chest X-ray findings had no significant correlation with the final diagnosis of PTE. Overall, 38 women underwent CDS, one of whom presented with deep vein thrombosis. The serum D-dimer level was positive in three cases with documented PTE (normal in one patient with PTE), and the serum troponin-I level was positive in one case with the final diagnosis of PTE (normal level in two patients with PTE). Conclusions: Based on the findings, clinical symptoms and biochemical tests alone are not reliable for ruling in or ruling out PTE during pregnancy, and CTA and pulmonary ventilation/perfusion scan should be performed for these cases.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Evaluation of Pregnant Patients with Suspected Pulmonary Embolism: A Descriptive Cross-Sectional Study

et al. 2020

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“…Before the start of the study, local procedures for CT pulmonary angiography were adapted and standardized for pregnancy (e.g., a high flow rate of administration of contrast medium, a high concentration of contrast medium, a shallow breath hold [to avoid the Valsalva maneuver], and a reduced dose of radiation). 10 Patients in whom the diagnosis of pulmonary embolism was ruled out were followed for 3 months for the occurrence of symptomatic VTE.…”

Section: Methodsmentioning

confidence: 99%

“…9 Therefore, the diagnostic workup of pregnant women with suspected pulmonary embolism relies mainly on imaging of the chest (i.e., CT pulmonary angiography or ventilation-perfusion scanning), with associated potential harm to the mother and fetus through exposure to intravenous contrast enhancement and ionizing radiation. [10][11][12] Because of the lack of strong evidence for validated diagnostic algorithms, there is no consensus among international guidelines regarding the approach to take in the diagnosis of pulmonary embolism during pregnancy. [12][13][14] Recently, the YEARS study (Netherlands Trial Register number, NL4020) assessed the use of the diagnostic YEARS algorithm in men and women with clinically suspected pulmonary embolism.…”

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confidence: 99%

Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism

Pol

Tromeur

Bistervels

et al. 2019

Obstetrical &Amp; Gynecological Survey

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BACKGROUNDPulmonary embolism is one of the leading causes of maternal death in the Western world. Because of the low specificity and sensitivity of the d-dimer test, all pregnant women with suspected pulmonary embolism undergo computed tomographic (CT) pulmonary angiography or ventilation-perfusion scanning, both of which involve radiation exposure to the mother and fetus. Whether a pregnancy-adapted algorithm could be used to safely avoid diagnostic imaging in pregnant women with suspected pulmonary embolism is unknown. METHODSIn a prospective study involving pregnant women with suspected pulmonary embolism, we assessed three criteria from the YEARS algorithm (clinical signs of deep-vein thrombosis, hemoptysis, and pulmonary embolism as the most likely diagnosis) and measured the d-dimer level. Pulmonary embolism was ruled out if none of the three criteria were met and the d-dimer level was less than 1000 ng per milliliter or if one or more of the three criteria were met and the d-dimer level was less than 500 ng per milliliter. Adaptation of the YEARS algorithm for pregnant women involved compression ultrasonography for women with symptoms of deep-vein thrombosis; if the results were positive (i.e., a clot was present), CT pulmonary angiography was not performed. All patients in whom pulmonary embolism had not been ruled out underwent CT pulmonary angiography. The primary outcome was the incidence of venous thromboembolism at 3 months. The secondary outcome was the proportion of patients in whom CT pulmonary angiography was not indicated to safely rule out pulmonary embolism. RESULTSA total of 510 women were screened, of whom 12 (2.4%) were excluded. Pulmonary embolism was diagnosed in 20 patients (4.0%) at baseline. During follow-up, popliteal deep-vein thrombosis was diagnosed in 1 patient (0.21%; 95% confidence interval [CI], 0.04 to 1.2); no patient had pulmonary embolism. CT pulmonary angiography was not indicated, and thus was avoided, in 195 patients (39%; 95% CI, 35 to 44). The efficiency of the algorithm was highest during the first trimester of pregnancy and lowest during the third trimester; CT pulmonary angiography was avoided in 65% of patients who began the study in the first trimester and in 32% who began the study in the third trimester. CONCLUSIONSPulmonary embolism was safely ruled out by the pregnancy-adapted YEARS diagnostic algorithm across all trimesters of pregnancy. CT pulmonary angiography was avoided in 32 to 65% of patients. (Funded by Leiden University Medical Center and 17 other participating hospitals; Artemis Netherlands Trial Register number, NL5726.)

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confidence: 99%

Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism

Pol¹,

Tromeur²,

Bistervels³

et al. 2019

Obstetric Anesthesia Digest

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BACKGROUND Pulmonary embolism is one of the leading causes of maternal death in the Western world. Because of the low specificity and sensitivity of the d-dimer test, all pregnant women with suspected pulmonary embolism undergo computed tomographic (CT) pulmonary angiography or ventilation-perfusion scanning, both of which involve radiation exposure to the mother and fetus. Whether a pregnancy-adapted algorithm could be used to safely avoid diagnostic imaging in pregnant women with suspected pulmonary embolism is unknown. METHODS In a prospective study involving pregnant women with suspected pulmonary embolism, we assessed three criteria from the YEARS algorithm (clinical signs of deep-vein thrombosis, hemoptysis, and pulmonary embolism as the most likely diagnosis) and measured the d-dimer level. Pulmonary embolism was ruled out if none of the three criteria were met and the d-dimer level was less than 1000 ng per milliliter or if one or more of the three criteria were met and the d-dimer level was less than 500 ng per milliliter. Adaptation of the YEARS algorithm for pregnant women involved compression ultrasonography for women with symptoms of deep-vein thrombosis; if the results were positive (i.e., a clot was present), CT pulmonary angiography was not performed. All patients in whom pulmonary embolism had not been ruled out underwent CT pulmonary angiography. The primary outcome was the incidence of venous thromboembolism at 3 months. The secondary outcome was the proportion of patients in whom CT pulmonary angiography was not indicated to safely rule out pulmonary embolism. RESULTS A total of 510 women were screened, of whom 12 (2.4%) were excluded. Pulmonary embolism was diagnosed in 20 patients (4.0%) at baseline. During follow-up, popliteal deep-vein thrombosis was diagnosed in 1 patient (0.21%; 95% confidence interval [CI], 0.04 to 1.2); no patient had pulmonary embolism. CT pulmonary angiography was not indicated, and thus was avoided, in 195 patients (39%; 95% CI, 35 to 44). The efficiency of the algorithm was highest during the first trimester of pregnancy and lowest during the third trimester; CT pulmonary angiography was avoided in 65% of patients who began the study in the first trimester and in 32% who began the study in the third trimester. CONCLUSIONS Pulmonary embolism was safely ruled out by the pregnancy-adapted YEARS diagnostic algorithm across all trimesters of pregnancy. CT pulmonary angiography was avoided in 32 to 65% of patients.

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Computed tomography pulmonary angiography versus ventilation-perfusion lung scanning for diagnosing pulmonary embolism during pregnancy: a systematic review and meta-analysis

Cited by 69 publications

References 61 publications

Evaluation of Pregnant Patients with Suspected Pulmonary Embolism: A Descriptive Cross-Sectional Study

Evaluation of Pregnant Patients with Suspected Pulmonary Embolism: A Descriptive Cross-Sectional Study

Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism

Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism

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