Pulmonary embolism in pregnancy

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)
  • STEMI
  • Non-STEMI
  • Unstable angina
• 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

1. Bilateral LE Ultrasound

1. if Positive-->treat empirically for PE
2. if Negative-->CTA

CT (with shield) vs. V/Q is roughly equilivalent radiation exposure

American Thoracic Society In Pregnancy

• 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
  • 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

• Pulmonary Embolism