Pulmonary embolism in pregnancy: Difference between revisions
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*Incidence of VTE in pregnancy and postpartum is 1.72 per 1000<ref>James AH, et al. Venous thromboembolism during pregnancy and the postpartum period: Incidence, risk factors, and mortality. 2006; 194(5):1311–1315.</ref> | *Incidence of VTE in pregnancy and postpartum is 1.72 per 1000<ref>James AH, et al. Venous thromboembolism during pregnancy and the postpartum period: Incidence, risk factors, and mortality. 2006; 194(5):1311–1315.</ref> | ||
*The risk is significantly elevated in the 6 wks postpartum | *The risk is significantly elevated in the 6 wks postpartum | ||
**Risk of DVT equal in 1st and 2nd trimesters, higher risk in 3rd trimester and 3 weeks postpartum. <ref name="multiple"> Chan et al. Venous Thromboembolism and Antithrombotic Therapy in Pregnancy. 2014.</ref> | **Risk of DVT equal in 1st and 2nd trimesters, higher risk in 3rd trimester and 3 weeks postpartum. <ref name="multiple"> Chan et al. Venous Thromboembolism and Antithrombotic Therapy in Pregnancy. SOGC Guidelines. 2014.</ref> | ||
**PE most commonly occurs in postpartum. <ref name="multiple"> Chan et al. Venous Thromboembolism and Antithrombotic Therapy in Pregnancy. 2014.</ref> | **PE most commonly occurs in postpartum. <ref name="multiple"> Chan et al. Venous Thromboembolism and Antithrombotic Therapy in Pregnancy. SOGC Guidelines. 2014.</ref> | ||
*Risk returns to baseline by 12 wks postpartumm<ref>Kamel H, et al. Risk of a thrombotic event after the 6-week postpartum period. N Engl J Med. 2014; 370:1307-1315.</ref> | *Risk returns to baseline by 12 wks postpartumm<ref>Kamel H, et al. Risk of a thrombotic event after the 6-week postpartum period. N Engl J Med. 2014; 370:1307-1315.</ref> | ||
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==Management== | ==Management== | ||
*[[Heparin]] and [[Enoxaparin]] are safe (coumadin is not) | *[[Heparin]] and [[Enoxaparin]] are safe (coumadin is not) | ||
** Heparin 80 units/kg IV bolus followed by continuous infusion 18 units/kg/hr <ref name="multiple1"> Tintinalli's 7th edition</ref> | |||
** Enoxaparin 1 milligram/kg (100 IU/kg) SC every 12 or 24 h <ref name="multiple1"> Tintinalli's 7th edition</ref> | |||
==Disposition== | ==Disposition== | ||
Revision as of 05:08, 20 February 2015
Background
- Incidence of VTE in pregnancy and postpartum is 1.72 per 1000[1]
- The risk is significantly elevated in the 6 wks postpartum
- Risk returns to baseline by 12 wks postpartumm[3]
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[4][5]
Types
Clinical Features
Symptoms
According to the PIOPED II study, these are the most common presenting signs[6]
- Dyspnea at rest or with exertion (73%)
- Pleuritic chest pain (44%)
- Cough (37%)
- Orthopnea (28%)
- Calf or thigh pain and/or swelling (44%)
- Wheezing (21%)
- Hemoptysis (13%)
Signs
- Tachypnea (54%)
- Calf or thigh swelling, erythema, edema, tenderness, palpable cord (47%)
- Tachycardia (24%)
- Rales (18%)
- Decreased breath sounds (17%)
- Accentuated pulmonic component of the second heart sound (15%)
- JVD (14%)
- Fever (3%)
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[7]
- 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[8][9][10]
- 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
- ↑ James AH, et al. Venous thromboembolism during pregnancy and the postpartum period: Incidence, risk factors, and mortality. 2006; 194(5):1311–1315.
- ↑ 2.0 2.1 Chan et al. Venous Thromboembolism and Antithrombotic Therapy in Pregnancy. SOGC Guidelines. 2014.
- ↑ Kamel H, et al. Risk of a thrombotic event after the 6-week postpartum period. N Engl J Med. 2014; 370:1307-1315.
- ↑ 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.
- ↑ Stein PD et al. Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. Am J Med. 2007;120(10):871.
- ↑ 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
- ↑ 11.0 11.1 Tintinalli's 7th edition