Pulmonary embolism in pregnancy: Difference between revisions
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===D-Dimer=== | ===D-Dimer=== | ||
*D-Dimer MAY BE used with following limits with '''very poor evidence'''<ref>Kovac M. The use of D-dimer with new cutoff can be useful in diagnosis of venous thromboembolism in pregnancy. Eur J Obstet Gynecol Reprod Biol. 2010 Jan;148(1):27-30</ref><ref>http://blog.ercast.org/2013/04/pulmonary-embolism-in-pregnancy/</ref> | *D-Dimer MAY BE used with following limits with '''very poor evidence'''<ref>Kovac M. The use of D-dimer with new cutoff can be useful in diagnosis of venous thromboembolism in pregnancy. Eur J Obstet Gynecol Reprod Biol. 2010 Jan;148(1):27-30</ref><ref>http://blog.ercast.org/2013/04/pulmonary-embolism-in-pregnancy/</ref><ref>D-Dimer Concentrations in Normal Pregnancy: New Diagnostic Thresholds Are Needed. Kline et all. Clinical Chemistry May 2005 vol. 51 no. 5 825-829 http://www.clinchem.org/content/51/5/825.long</ref> | ||
**1st trimester: <750 ng/mL (+50% increase from normal lab threshold) | **1st trimester: <750 ng/mL (+50% increase from normal lab threshold) | ||
**2nd trimester: <1000 ng/mL (+100% from normal) | **2nd trimester: <1000 ng/mL (+100% from normal) | ||
Revision as of 21:00, 29 November 2014
Background
Clinical Spectrum of Venous Thromboembolism
Clinical Spectrum of Venous thromboembolism (VTE)
- Deep venous thrombosis (uncomplicated)
- Phlegmasia alba dolens
- Phlegmasia cerulea dolens
- Venous gangrene
- Pulmonary embolism
- Isolated distal deep venous thrombosis
Only 40% of ambulatory ED patients with PE have concomitant DVT[1][2]
Types
Clinical Features
Symptoms
- Dyspnea at rest or with exertion (75-80%)
- Chest pain (66%)
- Pleuritic pain, pain that halts respiration, is only seen in 20% of patients
- Cough
- Hemoptysis
- Unilateral calf swelling
- Syncope
- Syncope is caused by PE <5% of the time
Signs
- Tachycardia (HR>100), Tachypnea (RR>20), Hypoxemia (SpO2<95%) are seen ~50% of the time
- Hypotension (SBP<90) only seen 10% of the time, but largest predictor of mortality
- Unilateral calf tenderness or edema, suggestive of a DVT
- Other signs may include accentuated pulmonic component of second heart sound, JVD, or decreased breath sounds
Differential Diagnosis
Chest pain
Critical
- Acute coronary syndromes (ACS)
- Aortic dissection
- Cardiac tamponade
- Coronary artery dissection
- Esophageal perforation (Boerhhaave's syndrome)
- Pulmonary embolism
- Tension pneumothorax
Emergent
- Cholecystitis
- Cocaine-associated chest pain
- Mediastinitis
- Myocardial rupture
- Myocarditis
- Pancreatitis
- Pericarditis
- Pneumothorax
Nonemergent
- Aortic stenosis
- Arthritis
- Asthma exacerbation
- Biliary colic
- Costochondritis
- Esophageal spasm
- Gastroesophageal reflux disease
- Herpes zoster / Postherpetic Neuralgia
- Hypertrophic cardiomyopathy
- Hyperventilation
- Mitral valve prolapse
- Panic attack
- Peptic ulcer disease
- Pleuritis
- Pneumomediastinum
- Pneumonia
- Rib fracture
- Stable angina
- Thoracic outlet syndrome
- Valvular heart disease
- Muscle sprain
- Psychologic / Somatic Chest Pain
- Spinal Root Compression
- Tumor
Workup
- If clinical features suggestive of PE and lower extremity swelling then
- Bilateral LE Ultrasound
- if Positive-->treat empirically for PE
- if Negative-->CTA
- CT (with shield) vs. V/Q is roughly equilivalent radiation exposure
American Thoracic Society In Pregnancy[3]
- D-dimer is not recommended for excluding PE (weak recommendation, very-low-quality evidence).
- If signs and symptoms of deep venous thrombosis (DVT), first perform bilateral venous compression ultrasound (CUS) of lower extremities, followed by anticoagulation treatment if positive and by further testing if negative (weak recommendation, very-low-quality evidence).
- If no signs and symptoms of DVT, pulmonary vascular imaging should be used over bilateral lower extremity ultrasounds(weak recommendation, very-low-quality evidence).
D-Dimer
- D-Dimer MAY BE used with following limits with very poor evidence[4][5][6]
- 1st trimester: <750 ng/mL (+50% increase from normal lab threshold)
- 2nd trimester: <1000 ng/mL (+100% from normal)
- 3rd trimester: <1250 ng/mL (+150% from normal)
Management
- Heparin and Enoxaparin are safe (coumadin is not)
Disposition
Admit
See Also
Sources
- ↑ Righini M, Le GG, Aujesky D, et al. Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. Lancet. 2008; 371(9621):1343-1352.
- ↑ Daniel KR, Jackson RE, Kline JA. Utility of the lower extremity venous ultrasound in the diagnosis and exclusion of pulmonary embolism in outpatients. Ann Emerg Med. 2000; 35(6):547-554.
- ↑ Leung, A et al. An Official American Thoracic Society/Society of Thoracic Radiology Clinical Practice Guideline: Evaluation of Suspected Pulmonary Embolism PDF
- ↑ Kovac M. The use of D-dimer with new cutoff can be useful in diagnosis of venous thromboembolism in pregnancy. Eur J Obstet Gynecol Reprod Biol. 2010 Jan;148(1):27-30
- ↑ http://blog.ercast.org/2013/04/pulmonary-embolism-in-pregnancy/
- ↑ D-Dimer Concentrations in Normal Pregnancy: New Diagnostic Thresholds Are Needed. Kline et all. Clinical Chemistry May 2005 vol. 51 no. 5 825-829 http://www.clinchem.org/content/51/5/825.long