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Bhangu G, Murray A, Qayyum A, Goumeniouk N, Goodacre S, Hunt BJ, Touhami O, Tester J, Rees M, Hammerschlag G, Pascoe D, Ronksley PE, King JA, Choi H, McDermott S, Le Gal G, Skeith L. Diagnostic strategies in postpartum individuals with suspected venous thromboembolism: A scoping review. Thromb Res 2024; 236:108-116. [PMID: 38422980 DOI: 10.1016/j.thromres.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/02/2024] [Accepted: 02/13/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND The risk of venous thromboembolism (VTE) is increased postpartum and contributes to important morbidity and mortality. While there have been advances in evaluating diagnostic algorithms for suspected VTE during pregnancy, there is limited data for postpartum individuals. OBJECTIVE We conducted a scoping review to describe and evaluate diagnostic strategies used to investigate suspected VTE in postpartum individuals. METHODS A comprehensive search strategy was conducted in Ovid MEDLINE, Embase and the Cochrane Central Register of Controlled Trials (January 1, 2000-September 30, 2022) to identify original articles that reported on diagnostic strategies in postpartum individuals with suspected VTE. We extracted demographics, clinical decision rules used, D-dimer and imaging completed, including test performance and VTE outcomes. RESULTS A total of 13 studies conducted across 11 countries with separate postpartum data were included for 759 individuals with suspected PE (n = 634) or DVT (n = 125), including unpublished data (n = 251). Among those with suspected PE, computed tomography pulmonary angiography was conducted more commonly (n = 522) than ventilation-perfusion scans (n = 69), with PE positivity rates that ranged from 4 %-27.6 % and 0-50 % across studies, respectively. Among 131 postpartum individuals with suspected PE who had a D-dimer measured, only 4.6 % (6/131) had a negative D-dimer test. For postpartum individuals with suspected DVT, the most common diagnostic test was compression ultrasonography (positivity rate 12.2 %-18.6 %). There were limited retrospective data evaluating the clinical decision rules. CONCLUSIONS There are heterogeneous approaches globally in the diagnosis of suspected postpartum VTE. Limited high-quality data available underscores the need for more robust evidence to inform clinical practice.
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Affiliation(s)
- Gurjeet Bhangu
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Alistair Murray
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Areeb Qayyum
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Natasha Goumeniouk
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Steve Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Beverley J Hunt
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Omar Touhami
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Hôpital Charles-LeMoyne, Sherbrooke University, Quebec, Canada
| | - Jodie Tester
- Department of Respiratory Medicine and Sleep Disorders, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Megan Rees
- Department of Respiratory Medicine and Sleep Disorders, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Gary Hammerschlag
- Department of Respiratory Medicine and Sleep Disorders, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Diane Pascoe
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia; Department of Radiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Paul E Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - James A King
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Alberta SPOR Support Unit Data Platform, Alberta Health Services, Calgary, Alberta, Canada
| | - Hyun Choi
- Emergency Department, University Hospital Lewisham, London, United Kingdom
| | - Shaunagh McDermott
- Thoracic Imaging Division, Department of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | - Gregoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Leslie Skeith
- Department of Medicine, University of Calgary, Calgary, AB, Canada; Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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2
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Sadeghi S, Arabi Z, Moradi M, Raofi E. Diagnostic imaging to investigate pulmonary embolism in pregnancy using CT-Pulmonary angiography versus perfusion scan. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2021; 26:37. [PMID: 34484369 PMCID: PMC8384013 DOI: 10.4103/jrms.jrms_113_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 07/22/2020] [Accepted: 01/18/2021] [Indexed: 11/17/2022]
Abstract
Background: Pulmonary embolism (PE) is one of the major causes of maternal mortality; however, its diagnosis based on clinical presentation is a significant challenge; therefore, imaging is required. This study aims to determine the nondiagnostic rate of PE in pregnant women who initially undergone computed tomographic pulmonary angiography (CTPA) or perfusion scan. Materials and Methods: In this cross-sectional study, all pregnant or 6-week postpartum women with clinical suspicion of PE were evaluated and underwent CTPA or perfusion scan between March 2017 and June 2019. The nondiagnostic rate of each method was defined as the outcome of this study. Results: One hundred and eighty-two women with a clinical suspicion of PE were included, among which the initial imaging method was CTPA in 122 (67.03%) and perfusion scan in 60 (32.97%) women. The nondiagnostic imaging for CTPA was significantly lower than the perfusion scan (9 cases (7.4%) versus 25 cases (41.7%), respectively). Logistic regression assessment revealed a statistical outcome by controlling the confounders including gestational trimester at diagnosis, hypertension, ejection fraction, and tachycardia (odds ratio 15.911, 95% confidence interval: 5.177–48.897, P < 0.001). Conclusion: Based on the current study, CTPA is superior to perfusion scans to diagnose PE among pregnant or postpartum women with normal chest X-ray suspicion for PE.
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Affiliation(s)
- Somayeh Sadeghi
- Aquired Immunodeficiency Research Center, School of Medicine, Al-Zahra Hospital, Isfahan University of Medicine Sciences, Isfahan, Iran
| | - Zahra Arabi
- Department of Internal Medicine, Medical School, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Maryam Moradi
- Department of Radiology, Medical School, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Elham Raofi
- Department of Internal Medicine, Medical School, Isfahan University of Medical Sciences, Isfahan, Iran
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Tester J, Hammerschlag G, Irving L, Pascoe D, Rees M. Investigation and diagnostic imaging of suspected pulmonary embolism during pregnancy and the puerperium: A review of the literature. J Med Imaging Radiat Oncol 2020; 64:505-515. [PMID: 32307898 DOI: 10.1111/1754-9485.13027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 02/16/2020] [Accepted: 02/23/2020] [Indexed: 11/27/2022]
Abstract
Pulmonary embolism (PE) is a leading cause of maternal mortality with women at increased risk of PE during pregnancy and the early postpartum period. Clinical assessment of suspected PE during pregnancy is challenging as signs and symptoms associated with PE overlap with physiological changes of pregnancy. Clinical tests and rules commonly used to assess pre-test probability of PE were historically not well validated in the pregnant population. The challenges of clinical assessment in the pregnant and postpartum population result in a lowered threshold for diagnostic imaging. Computed tomographic pulmonary angiography (CTPA) and nuclear medicine lung scintigraphy or ventilation/perfusion (V/Q) scans are the main types of diagnostic imaging for suspected PE. Both methods are associated with small levels of ionising radiation exposure to mother and foetus. Accuracy of the diagnostic imaging tests is paramount. Haemodynamic changes of pregnancy, including increased heart rate, increased blood volume and altered flow velocity in the pulmonary arteries, may influence the quality of imaging. This comprehensive review examines the literature and evidence for the investigation and diagnostic imaging of suspected pulmonary embolism during pregnancy with CTPA and V/Q. Clinical decision-making tools, biomarkers and diagnostic imaging during pregnancy and postpartum will be considered with a focus on diagnostic accuracy and yield, radiation dose exposure (maternal-foetal) and protocol modifications. Current practice guideline recommendations and recent literature on diagnostic pathways are also presented.
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Affiliation(s)
- Jodie Tester
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Gary Hammerschlag
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Louis Irving
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Diane Pascoe
- Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Radiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Megan Rees
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
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Cohen SL, Wang J, Mankerian M, Feizullayeva C, McCandlish JA, Barnaby D, Sanelli P, McGinn T. Evaluation of CTPA interpreted as limited in pregnant patients suspected for pulmonary embolism. Emerg Radiol 2019; 27:165-171. [PMID: 31813073 DOI: 10.1007/s10140-019-01728-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 09/06/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE The purpose of this study is to determine the rates of CT pulmonary angiography (CTPA) interpreted as limited and severely limited in pregnant patients suspected for pulmonary embolism (PE), and to evaluate factors that influence these rates. METHODS This is a retrospective study with CTPA for evaluation of PE in pregnancy across a large health system from 2006 to 2017. CTPA was classified as limited from the radiology report with a subset of those studies classified as severely limited. Bivariate and multivariate analysis was performed for limited and severely limited rates with maternal age and patient size as a continuous variable and race, trimester, patient location study priority status, and result of chest radiograph before CTPA as categorical variables. RESULTS 874 patients with 33% of studies limited and 4% of studies severely limited. Multivariate logistic regression of CTPA studies revealed decreasing patient age (OR 0.967, p = 0.0129) and increasing patient size (OR 1.013, p < 0.0001). Studies performed in the second trimester (OR 1.869, p = 0.0242) and third trimester (OR 2.314, p = 0.0021) were more likely to be reported as limited (each p < 0.05). Increasing patient size (OR 1.017, p = 0.0046) was the only significant predictor of severely limited versus non-severely limited studies. CONCLUSION CTPA interpreted as limited in pregnancy are common and may be associated with younger age, larger patient size, and second and third trimesters. However, severely limited interpretations are much less common, with patient size the only significant predictor.
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Affiliation(s)
- S L Cohen
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA. .,Northwell Health Imaging, 600 Community Drive, Manhasset, NY, 11030, USA. .,Imaging Clinical Effectiveness & Outcomes Research Program at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA. .,Feinstein Institute for Medical Research at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA.
| | - J Wang
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Imaging Clinical Effectiveness & Outcomes Research Program at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA.,Feinstein Institute for Medical Research at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA
| | - M Mankerian
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - C Feizullayeva
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Northwell Health Imaging, 600 Community Drive, Manhasset, NY, 11030, USA.,Imaging Clinical Effectiveness & Outcomes Research Program at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA.,Feinstein Institute for Medical Research at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA
| | | | - D Barnaby
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Feinstein Institute for Medical Research at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA.,Northwell Health Emergency Medicine, Manhasset, NY, USA
| | - P Sanelli
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Northwell Health Imaging, 600 Community Drive, Manhasset, NY, 11030, USA.,Imaging Clinical Effectiveness & Outcomes Research Program at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA.,Feinstein Institute for Medical Research at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA
| | - T McGinn
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Feinstein Institute for Medical Research at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA.,Northwell Health Internal Medicine, Manhasset, NY, USA
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Tromeur C, van der Pol LM, Le Roux PY, Ende-Verhaar Y, Salaun PY, Leroyer C, Couturaud F, Kroft LJM, Huisman MV, Klok FA. Computed tomography pulmonary angiography versus ventilation-perfusion lung scanning for diagnosing pulmonary embolism during pregnancy: a systematic review and meta-analysis. Haematologica 2018; 104:176-188. [PMID: 30115658 PMCID: PMC6312023 DOI: 10.3324/haematol.2018.196121] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 08/14/2018] [Indexed: 01/19/2023] Open
Abstract
Differences between computed tomography pulmonary angiography and ventilation-perfusion lung scanning in pregnant patients with suspected acute pulmonary embolism are not well-known, leading to ongoing debate on which test to choose. We searched in PubMed, EMBASE, Web of Science and the Cochrane Library databases and identified all relevant articles and abstracts published up to October 1, 2017. We assessed diagnostic efficiency, frequency of non-diagnostic results and maternal and fetal exposure to radiation exposure. We included 13 studies for the diagnostic efficiency analysis, 30 for the analysis of non-diagnostic results and 22 for the radiation exposure analysis. The pooled rate of false negative test results was 0% for both imaging strategies with overlapping confidence intervals. The pooled rates of non-diagnostic results with computed tomography pulmonary angiography and ventilation-perfusion lung scans were 12% (95% confidence interval: 8-17) and 14% (95% confidence interval: 10-18), respectively. Reported maternal and fetal radiation exposure doses were well below the safety threshold, but could not be compared between the two diagnostic methods given the lack of high quality data. Both imaging tests seem equally safe to rule out pulmonary embolism in pregnancy. We found no significant differences in efficiency and radiation exposures between computed tomography pulmonary angiography and ventilation-perfusion lung scanning although direct comparisons were not possible.
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Affiliation(s)
- Cécile Tromeur
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands .,Groupe d'Etude de la Thrombose de Bretagne Occidentale, University of Brest, Equipe d'Accueil 3878, Department of Internal Medicine and Chest Diseases, CHRU Brest, France.,Centre d'Investigation Clinique INSERM 1412, University of Brest, France
| | - Liselotte M van der Pol
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands.,Department of Internal Medicine, Haga Teaching Hospital, the Hague, the Netherlands
| | | | - Yvonne Ende-Verhaar
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
| | | | - Christophe Leroyer
- Groupe d'Etude de la Thrombose de Bretagne Occidentale, University of Brest, Equipe d'Accueil 3878, Department of Internal Medicine and Chest Diseases, CHRU Brest, France.,Centre d'Investigation Clinique INSERM 1412, University of Brest, France
| | - Francis Couturaud
- Groupe d'Etude de la Thrombose de Bretagne Occidentale, University of Brest, Equipe d'Accueil 3878, Department of Internal Medicine and Chest Diseases, CHRU Brest, France.,Centre d'Investigation Clinique INSERM 1412, University of Brest, France
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, the Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
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6
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Abstract
Advances in the management of patients with suspected pulmonary embolism (PE) have improved diagnostic accuracy and made management algorithms safer, easier to use, and well standardized. These diagnostic algorithms are mainly based on the assessment of clinical pretest probability, D-dimer measurement, and imaging tests-predominantly computed tomography pulmonary angiography. These diagnostic algorithms allow safe and cost-effective diagnosis for most patients with suspected PE. In this review, we summarize signs and symptoms of PE, current existing evidence for PE diagnosis, and focus on the challenge of diagnosing PE in special patient populations, such as pregnant women, or patients with a prior VTE. We also discuss novel imaging tests for PE diagnosis and highlight some of the additional challenges that might require adjustments to current diagnostic strategies, such as the reduced clinical suspicion threshold, resulting in a lower proportion of PE among suspected patients as well as the overdiagnosis of subsegmental PE.
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Affiliation(s)
- M Righini
- Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - H Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - G Le Gal
- Ottawa Hospital Research Institute, Ottawa, Canada
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7
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Adibi A, Nouri S, Moradi M, Shahabi J. Clinical and echocardiographic findings of patients with suspected acute pulmonary thromboembolism who underwent computed tomography pulmonary angiography. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2017; 21:118. [PMID: 28255326 PMCID: PMC5331763 DOI: 10.4103/1735-1995.193509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 08/01/2016] [Accepted: 08/20/2016] [Indexed: 11/04/2022]
Abstract
Background: The aim of the study was to determine the correlation between clinical and echocardiographic findings and risk factors of patients with suspected acute pulmonary thromboembolism (PTE) who underwent computed tomography pulmonary angiography (CTPA). Materials and Methods: In this cross-sectional study, 310 hospitalized patients aged >18 years with high clinical suspicion of PTE referred to imaging center of our hospital from different wards for CTPA were enrolled. The frequency of different clinical presentations, risk factors, items of Wells’ criteria, and echocardiographic findings was compared in patients with and without PTE, which have been diagnosed according to the CTPA results. Results: PTE was diagnosed in 53 (17.1%) of patients with suspected PTE. From clinical manifestations, tachypnea, pleuritic chest pain, and edema of lower extremities were significantly more frequent among patients with PTE (P < 0.05). Major surgery was the risk factor which was significantly more prevalent among patients with PTE (P < 0.05). Frequency of all criteria of Wells’ criteria, except hemoptysis, was significantly higher in patients with PTE (P < 0.05). The frequency of all studied echocardiographic variables was significantly higher in patients with PTE (P < 0.05). Conclusion: It is suggested that we could use the results of this study for utilizing the diagnostic process of PTE in patients with highly clinical suspicion of PTE and providing more validated decision. Using the results of this study, we could identify high-risk patients and made appropriate risk assessment for better management of patients with suspected PTE as well as reduce the rate of unnecessary CTPA and its related adverse consequences.
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Affiliation(s)
- Atoosa Adibi
- Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shadi Nouri
- Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Maryam Moradi
- Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Javad Shahabi
- Department of Cardiology, Isfahan University of Medical Sciences, Isfahan, Iran
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