Evaluation and Initial Management of Pulmonary Embolism during Pregnancy and the Puerperium
There is an increased risk of venous thromboembolism during pregnancy.
The increased risk begins in the first trimester and remains until six weeks postpartum.
This paper provides an update on diagnosing and managing pulmonary embolism in pregnancy.
Initial workup includes a clinical assessment, baseline blood test, electrocardiogram and a chest radiograph.
D-dimer test is not recommended during pregnancy and puerperium.
Doppler ultrasound of lower limb is recommended in the presence of a clinical suspicion
of deep vein thrombosis. Definitive diagnosis of pulmonary embolism is established with radiological imaging.
The preferred imaging modality is isotope perfusion scan with a normal chest radiograph and
computed tomographic pulmonary angiography if chest radiograph is abnormal.
Therapeutic low molecular weight heparin is the anticoagulant of choice during pregnancy.
Warfarin is contraindicated during pregnancy but can be used postpartum.
Duration of therapy is at least three months and should continue for six weeks postpartum.
An algorithm for diagnosis and management is suggested
The prevalence of Venous thromboembolism is 4 to 10 times higher in pregnancy
than age matched non-pregnant women.
The increased risk of VTE extends from the first trimester until six weeks postpartum
Pregnancy is a prothrombotic state. Physiological changes occur during pregnancy,
notably an increase in plasma coagulation factors, fibrinogen and Von Willebrand factor, all of
which disrupt the normal homeostatic balance.
One retrospective cohort study reported a previous history of thrombosis as being
the most significant individual risk factor for VTE.
Another recent cohort study showed 17-fold higher risk of VTE
during hospital admission not related to delivery, with highest
risk in third trimester, remaining significantly higher up to 28
days post-discharge.
Emerg Med Open J. 2015; 1(3): 72-76. doi: 10.17140/EMOJ-1-112