Morning Report

Morning Report: 4/3/2015

by  •  • Comments Off on Morning Report: 4/3/2015

Dr. Grock presents today’s Morning Report!

 

Case:

32 F 18 wks by LMP presents with chest pain: sharp, non-exertional, 7/10, mildly decreased ET, bilat LE edema.

VS HR 102, BP 130/74, RR 20, Temp 99.8 oral, O2sat 98% on RA.

 

What are you worried about?

PE?

MI?

 

Let’s start with PE. Work-up? PE?

Some use, some don’t.

  1. PERC/Wells/Geneva – not validated for pregnancy
  2. Do you use D-Dimer?

 

ATS 2011 – don’t use d-dimer (weak recommendation, very low quality evidence).

– All low quality or very low quality evidence

 

Kline et al. D-Dimer Concentrations in Normal Pregnancy: New Diagnostic Thresholds Are Needed. 50 pt’s got dimers, excluded other causes that would elevate dimer – pre-preg (estimated 60% would get pregnant?!), 1st trimester, 2nd trimester, 3rd trimester, 4 wks post-partum. Results: Mean increase in Dimer per trimester: 0.16, 0.41, 0.69, 0.2.

 

Cogley et al. PE Evaluation in the Pregnant Patient: A Review of Current Imaging Approaches – neg dimer rules out PE.

 

  1. US – YES
  2. CXR – YES: evaluate the patient for other causes of her symptoms.
  3. CTA vs V/Q – V/Q has technetium which is excreted in the urine. The baby is then exposed to the radiation as this goes from kidney to bladder. CTA has LESS radiation to the BABY, but MORE radiation to the MOM.
    1. Per ATS: No preferences. Equally effective. For V/Q can only do Q scan (if nml, no V scan).
    2. Per ACR: CTA better (less non-diagnostic studies).

 

So now you know everything about diagnosing PE in pregnancy. But what if I told you the prevalence of PE in pregnancy is NOT what you thought!?

 

Kline et al. Systematic Review and Meta-analysis of Pregnant Patients Investigated for Suspected PE in the ED – 17 studies with 25,339 patients worked up for PE, VTE+ rate 4.1% (21/506) vs 12.4% among non-pregnant patients. Ref: in Minnesota, rate of VTE 32/100,000 – same as all women under 40 in the same region. In the UK, rate of VTE 20/100,000 vs 55/100,000 for pregnant + 1 VTE risk factor. 70% of VTE occur during delivery and postpartum and PE 3/100,000 pregnancies.

 

References:

  • Leung et al. An Official American Thoracic Society/Society of Thoracic Radiology Clinical Practice Guidline: Evaluation of Suspected Pulmonary Embolism In Pregnancy. AM J Respir Crit Care Med Vol 184. Pp1200-1208. 2011
  • Kline et al. D-Dimer Concentrations in Normal Pregnancy: New Diagnostic Thresholds Are Needed. Clin Chem 51:5, 825-829. 2005
  • Cogley et al. PE Evaluation in the Pregnant Patient: A Review of Current Imaging Approaches. Semin US CT MRI 33:11-17. 2012
  • Bettmann et al. Acute Chest Pain – Suspected Pulmonary Embolism. American College of Radiology ACR Appropriateness Criteria. 2011
  • Kline et al. Systematic Review and Meta-analysis of Pregnant Patients Investigated for Suspected PE in the ED. Acad Emerg Med. 2014 Sep;21(9):949-59
The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
The following two tabs change content below.
My Twitter profileMy Facebook profileMy Vimeo channel

Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital
My Twitter profileMy Facebook profileMy Vimeo channel

Latest posts by Jay Khadpe MD (see all)