Tuesday, 16 October 2018

Possible PE in pregnancy

Possible PE in pregnancy is a nightmare to investigate and to manage. There are several flowcharts...but lets look at the evidence. 1. Is this a PE? Has someone just done a random d-dimer? If they have...think back to the symptoms. We know shortness of breath in pregnancy could have many causes, but we only worry about PE. Take a good history. Anecdotal evidence suggests PEs should be tachycardic. 2. Do a CXR A whole load of investigating is prevented if they've got a pneumothorax or pneumonia. 3. Risk stratify If they're high risk, they need imaging. If they're low risk...continue. 4. In a low risk patient, a negative d-dimer is considered able to rule out VTE. Chances of it being negative are slim. The DiPep study recommends not using d-dimers, as does the RCOG greentop guideline. 5. Consider trimester adjusted d-dimers. We know the d-dimer rises in pregnancy. These values will depend on your d-dimer assay. 1st 750 ng/dL, 2nd 1000 ng/dL, and 3rd 1250 ng/dL D-dimer test with the new threshold for: the first of 286, the second of 457 and the third trimester of 644 ng/mL can be useful in diagnosis of pregnancy related VTE. I can't find any strong evidence these are strongly evidence based - but Jeff Kline is amazingly knowledgable, so I'm sure he's right! 6. Imaging Bilateral leg dopplers - if they're positive for DVT...start treatment VQ scan - probably causes more radiation to the fetus Other Summaries https://emcrit.org/wp-content/uploads/2011/07/PE-DX-by-Jeff-Kline.pdf https://www.aci.health.nsw.gov.au/networks/eci/clinical/clinical-resources/clinical-tools/respiratory/pe/pe-pregnant

No comments:

Post a comment