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Meta-Analysis
. 2023 Mar;21(3):606-615.
doi: 10.1016/j.jtha.2022.11.025. Epub 2022 Dec 22.

Noninvasive diagnostic work-up for suspected acute pulmonary embolism during pregnancy: a systematic review and meta-analysis of individual patient data

Milou A M Stals  1 , Thomas Moumneh  2 , Fionnuala Ni Ainle  3 , Drahomir Aujesky  4 , Thomas van Bemmel  5 , Laurent Bertoletti  6 , Ingrid M Bistervels  7 , Céline Chauleur  8 , Francis Couturaud  9 , Yordi P A van Dooren  10 , Antoine Elias  11 , Laura M Faber  12 , Catherine Le Gall  13 , Herman M A Hofstee  14 , Tom van der Hulle  1 , Marieke J H A Kruip  15 , Maxime Maignan  16 , Albert T A Mairuhu  17 , Saskia Middeldorp  18 , Emmanuelle Le Moigne  9 , Mathilde Nijkeuter  19 , Liselotte M van der Pol  1 , Helia Robert-Ebadi  20 , Pierre-Marie Roy  2 , Olivier Sanchez  21 , Jeannot Schmidt  22 , Maarten van Smeden  23 , Cecile Tromeur  9 , Marije Ten Wolde  24 , Marc Righini  25 , Grégoire Le Gal  26 , Menno V Huisman  1 , Frederikus A Klok  27
Affiliations
Meta-Analysis

Noninvasive diagnostic work-up for suspected acute pulmonary embolism during pregnancy: a systematic review and meta-analysis of individual patient data

Milou A M Stals et al. J Thromb Haemost. 2023 Mar.

Abstract

Background: Few studies evaluated the performance of noninvasive diagnostic strategies for suspected acute pulmonary embolism (PE) in pregnant women.

Objectives: The aim of this study was to establish the safety and efficiency of the Wells rule with fixed and adapted D-dimer threshold, and the YEARS algorithm, combined with compression ultrasonography (CUS), in pregnant women with suspected PE in an individual patient data meta-analysis.

Methods: We performed a systematic review to identify prospective diagnostic management studies in pregnant women with suspected PE. Primary outcomes were safety, defined as the failure rate, ie, the 3-month venous thromboembolism (VTE) incidence after excluding PE without chest imaging, and efficiency, defined as the proportion of patients in whom chest imaging could be avoided.

Results: We identified 2 relevant studies, of which individual patient-level data were analyzed in a fixed-effect meta-analysis, totaling 893 pregnant women. The Wells rule with fixed and adapted D-dimer threshold as well as the YEARS algorithm could safely rule out acute PE (failure rate, 0·37%-1·4%), but efficiency improved considerably when applying pretest probability-adapted D-dimer thresholds. The efficiency of bilateral CUS was limited (2·3% overall; number needed to test 43), especially in patients without symptoms of deep-vein thrombosis (efficiency 0·79%; number needed to test 127).

Conclusion: This study supports the latest guideline recommendations (European Society of Cardiology 2019) to apply pretest probability assessment and D-dimer tests to rule out PE in pregnant women. From an efficiency perspective, the use of a strategy with pretest probability-adapted D-dimer threshold is preferred. The yield of CUS was very limited in patients without concomitant symptoms of deep-vein thrombosis.

Keywords: D-dimer; diagnosis; pregnancy; pulmonary embolism; ultrasonography.

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