Diagnosis of Pulmonary Embolism in Pregnant Women

The issues raised by the management of suspected pulmonary embolism (PE) in pregnant women in the emergency department are numerous. The physiological changes during pregnancy increase the number of emergency visits for chest pain, dyspnoea, faintness, etc. These manifestations during pregnancy can be identified as suggestive of PE and interfere with our ability to assess its probability. Finally, the physiological elevation of D-dimers and the rate of nonconclusive chest imaging complexify the diagnostic pathway. However, it is in the context of pregnancy that it is especially desirable not to miss a diagnosis of PE, while avoiding unnecessary exposure of the patient and her fetus to chest imaging. To assist in decision making, two strategies have been validated in the context of pregnancy. The first is based on the Geneva score, which includes performing a proximal compression ultrasound in patients with a high probability or with a D-dimer greater than 500 mu g/L. The second is based on the YEARS algorithm, with ultrasound performed only in patients with symptoms suggestive of associated lower limb venous thrombosis, followed by D-dimer testing with a threshold of 500 or 1,000 mu g/L depending on clinical probability. The safety of these two strategies has been demonstrated. The advantage of the first strategy is that it is based on objective data only, and the second strategy has the advantage of using a decision threshold of 1,000 mu g/L in patients without any of the YEARS criteria.