The DiPEP Study: An Observational Study of the Diagnostic Accuracy of Clinical Assessment, D-dimer and Chest X-ray for Suspected Pulmonary Embolism in Pregnancy and Postpartum

Goodacre, Steve; Horspool, Kimberley; Nelson‐Piercy, C; Knight, Marian; Shephard, Neil; Lecky, FE; Thomas, Steven; Hunt, B. J.; Fuller, Gordon

doi:10.1097/01.aoa.0000603808.91052.ed

Cited by 4 publications

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“…were not valid or clinically useful in pregnant and postpartum women. [32][33][34] Seven studies describing social determinants of health and postpartum ED use were included (►Table 4). Five studies were from the United States, one from Canada, and one from Bangladesh and Burkina Faso.…”

Section: D-dimers and Clinical Decision Rules To Address The Likeliho...mentioning

confidence: 99%

Care of the Postpartum Patient in the Emergency Department: A Systematic Review with Implications for Maternal Mortality

Mitchell

Haddock

Husainy³

et al. 2021

Am J Perinatol

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Objective Approximately one-third of maternal deaths occur postpartum. Little is known about the intersection between the postpartum period, emergency department (ED) use, and opportunities to reduce maternal mortality. The primary objectives of this systematic review are to explore the incidence of postpartum ED use, identify postpartum disease states that are evaluated in the ED, and summarize postpartum ED use by race/ethnicity and payor source. Study Design We searched PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov, Cochrane CENTRAL, Social Services Abstracts, and Scopus from inception to September 19, 2019. Each identified abstract was screened by two authors; the full-text manuscripts of all studies deemed to be potential candidates were then reviewed by the same two authors and included if they were full-text, peer-reviewed articles in the English language with primary patient data reporting care of a female in the ED in the postpartum period, defined as up to 1 year after the end of pregnancy. Results A total of 620 were screened, 354 records were excluded and 266 full-text articles were reviewed. Of the 266 full-text articles, 178 were included in the systematic review; of these, 108 were case reports. Incidence of ED use by postpartum females varied from 4.8 to 12.2% in the general population. Infection was the most common reason for postpartum ED evaluation. Young females of minority race and those with public insurance were more likely than whites and those with private insurance to use the ED. Conclusion As many as 12% of postpartum women seek care in the ED. Young minority women of lower socioeconomic status are more likely to use the ED. Since approximately one-third of maternal deaths occur in the postpartum period, successful efforts to reduce maternal mortality must include ED stakeholders. Systematic Review Registration CRD42020151126. Key Points

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Section: D-dimers and Clinical Decision Rules To Address The Likeliho...mentioning

confidence: 99%

Care of the Postpartum Patient in the Emergency Department: A Systematic Review with Implications for Maternal Mortality

Mitchell

Haddock

Husainy³

et al. 2021

Am J Perinatol

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“…Pregnant patients were excluded from the derivation studies, and relatively few prospective data have been published to validate the tools in this population. 44,45,[48][49][50][51][79][80][81][82] Because those guidelines were published, 3 studies have delivered the first high-quality research on this topic:…”

Section: Clinical Decision Rulesmentioning

confidence: 99%

“…Routine physiologic changes of pregnancy often produce dyspnea, lower extremity edema, and resting tachycardia that mimic signs and symptoms of PE, thereby presenting a challenge for physicians to assess the presence of PE based on clinical factors alone. For example, among pregnant and postpartum women tested for PE in the DiPEP study, those with PE had similar rates of pleuritic chest pain (52%), dyspnea (54%), palpitations (13%), cough (8%), and syncope (5%) compared with women without PE 45 . In that study, variables associated with PE included older age, lower oxygen saturation, lower systolic blood pressure, and temperature; however, these continuous variables often provide little value for distinguishing PE from other common conditions on the basis of physical examination alone.…”

Section: Clinical Presentationmentioning

confidence: 99%

“…For example, among pregnant and postpartum women tested for PE in the DiPEP study, those with PE had similar rates of pleuritic chest pain (52%), dyspnea (54%), palpitations (13%), cough (8%), and syncope (5%) compared with women without PE. 45 In that study, variables associated with PE included older age, lower oxygen saturation, lower systolic blood pressure, and temperature; however, these continuous variables often provide little value for distinguishing PE from other common conditions on the basis of physical examination alone. Furthermore, many patients with PE have normal vital signs.…”

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confidence: 97%

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Venous Thromboembolism During Pregnancy and the Postpartum Period: Risk Factors, Diagnostic Testing, and Treatment

Maughan

Marín

Han

et al. 2022

Obstetrical &Amp; Gynecological Survey

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Importance: The risk of venous thromboembolism (VTE) increases during pregnancy and the postpartum period. Deep vein thrombosis is the most common VTE during pregnancy, but pulmonary embolism is typically of greater concern as it contributes to far higher morbidity and mortality. Diagnosis and treatment of VTE during pregnancy differ substantially from the general nonpregnant population.Objective: This review describes the epidemiology, risk factors, clinical presentation, diagnosis, and treatment of VTE during pregnancy and the postpartum period.Evidence Acquisition: First, we reviewed the VTE guidelines from professional societies in obstetrics, cardiology, hematology, emergency medicine, pulmonology, and critical care. Second, we examined references from these documents and used PubMed to identify recent articles that cited the guidelines. Finally, we searched PubMed and Google Scholar for articles published since 2018 that included terms for pregnancy and the epidemiology, risk factors, diagnostic imaging, or treatment of VTE.Results: Venous thromboembolism risk increases throughout pregnancy and peaks shortly after delivery. More than half of pregnancy-related VTE are associated with thrombophilia; other major risks include cesarean delivery, postpartum infection, and the combination of obesity with immobilization. Most VTE can be treated with low molecular weight heparin, but cases of limb-or life-threatening VTE require consideration of thrombolysis and other reperfusion therapies.Conclusions and Relevance: Venous thromboembolism is far more frequent in antepartum and postpartum women than age-matched controls, and clinical suspicion for VTE in this population should incorporate pregnancy-specific B.C.M. received support from the Oregon Emergency Care Research Multidisciplinary Training Program (5K12HL133115). K.J.G.

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“…Goodacre et al 44 used a cohort study augmented by additional confirmed cases of PE from the UK Obstetric Surveillance System. These investigators found that both clinical and D-dimer criteria for further imaging studies showed high sensitivity only at the expense of very low specificity.…”

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confidence: 99%

Diagnosis of Pulmonary Embolism in Pregnancy

et al. 2023

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Pulmonary embolism (PE) is a significant cause of obstetric morbidity and mortality. However, over diagnosis related to excessive use of diagnostic testing is also associated with long term major health issues, including impact on future pregnancies and subsequent health care. Accurate diagnosis of PE depends on knowledge of the prevalence of PE in the pregnant population, the a priori probability of a PE based on specific findings in a given patient and understanding of the accuracy of computed tomographic pulmonary arteriography (CTPA), the dominant diagnostic modality employed for this diagnosis. Venous thromboembolism (VTE) is widely considered to be more common in pregnancy. However, this term includes both deep venous thrombosis (DVT) as well as PE. While the former appears to be more common, published data on the prevalence of PE in pregnancy show little or no increase relative to the general population. Given the published data on the sensitivity and specificity of CTPA, a positive reading is more likely to be a false positive unless the probability of a PE in a given patient is at least 5% (a two-hundred-fold increase from baseline). Doubling the probability to 10% (a four-hundred-fold increase) only improves the positive predictive value to about 67%. Strategies to refine the a priori probability of a PE in a given patient are detailed, including scoring systems and D-dimer measurements. A careful history and physical examination and thoughtful development of a differential diagnosis are key elements of clinical practice and should include both the likelihood of each possible diagnosis and the accuracy of diagnostic modalities. This approach should precede the application of a given algorithm. Such a structured approach can decrease utilization and limit false positive diagnoses without increasing morbidity or mortality.

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The DiPEP Study: An Observational Study of the Diagnostic Accuracy of Clinical Assessment, D-dimer and Chest X-ray for Suspected Pulmonary Embolism in Pregnancy and Postpartum

Cited by 4 publications

References 0 publications

Care of the Postpartum Patient in the Emergency Department: A Systematic Review with Implications for Maternal Mortality

Care of the Postpartum Patient in the Emergency Department: A Systematic Review with Implications for Maternal Mortality

Venous Thromboembolism During Pregnancy and the Postpartum Period: Risk Factors, Diagnostic Testing, and Treatment

Diagnosis of Pulmonary Embolism in Pregnancy

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