Can the Pregnancy-Adapted YEARS Algorithm be Used to Rule Out Pulmonary Embolism?
BACKGROUND AND PURPOSE:
Pulmonary embolism (PE) results in 1 death per 100,000 deliveries and is associated with maternal mortality
Women with suspected PE undergo CT pulmonary angiography or ventilation–perfusion scan
Medically warranted but does result in radiation exposure
Van der Pol et al. (NEJM, 2019) investigated whether a pregnancy-adapted algorithm including d-dimer test could be used as an alternative to CT scan
Prospective, multicenter study
Pregnant women with suspected pulmonary embolism
Worsening chest pain or dyspnea +/- hemoptysis or tachycardia
Extension of YEARS study (started in 2013) to include exclusively pregnant women
Assessed three criteria from the YEARS algorithm
Clinical signs of DVT
Pulmonary embolism considered likely diagnosis based on history and physical
Measured d-dimer level
Pulmonary embolism was ruled out and treatment withheld if either
None of the three criteria were met and d-dimer level <1000 ng/mL
≥1 of the 3 assessment criteria met and d-dimer level was <500 ng per milliliter
Pregnancy adaptation: If DVT symptoms present, compression ultrasound performed
Positive (clot was present): PE diagnosis considered established and continued to treatment with no other diagnostic imaging
Negative (normal ultrasound): Continue to algorithm
Incidence of venous thromboembolism (VTE) at 3 months confirmed objectively in rule out group
Proportion of patients in whom CT pulmonary angiography was not indicated to safely rule out pulmonary embolism, compared to hypothetical cohort where all patients would have had CT pulmonary angiography or ventilation–perfusion scanning
498 women included
PE diagnosis at baseline: 4.0% at baseline
VTE diagnosis during follow-up
0.21% (n=1) with popliteal deep-vein thrombosis (95% CI, 0.04 to 1.2)
CT pulmonary angiography
Not indicated (avoided): 39% (95% CI, 35 to 44)
Efficiency of algorithm highest during the first trimester of pregnancy and lowest during the third trimester
1st trimester: 65% avoided
3rd trimester: 32% avoided
The pregnancy-adapted YEARS diagnostic algorithm can be used to rule out pulmonary embolism throughout pregnancy
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