Skip to main content
SpringerLink
Log in

Imaging modalities for confirming pulmonary embolism during pregnancy: results from a multicenter international study

  • Computed Tomography
  • Published:
European Radiology Aims and scope Submit manuscript

Abstract

Objectives

We explored the variations in use of imaging modalities for confirming pulmonary embolism (PE) according to the trimester of pregnancy.

Methods

We included all pregnant patients with confirmed acute PE from RIETE, a prospective registry of patients with PE (03/2001–02/2020). Imaging modalities included computed tomography pulmonary angiography (CTPA), ventilation-perfusion (V/Q) scan, or presence of signs of acute PE along with imaging-confirmed proximal deep vein thrombosis (pDVT) without pulmonary vascular imaging. We compared the imaging modalities to postpartum patients with PE, and other non-pregnant women with PE.

Results

There were 157 pregnant patients (age: 32.7 ± 0.5), 228 postpartum patients (age: 33.9 ± 0.5), and 23,937 non-pregnant non-postpartum women (age: 69.5 ± 0.1). CTPA was the most common modality for confirming PE, from 55.7% in first trimester to 58.3% in second trimester, and 70.0% in third trimester. From first trimester to third trimester, V/Q scanning was used in 21.3%, 16.7%, and 18.3% of cases, respectively. Confirmed pDVT along with the presence of signs/symptoms of PE was the confirmatory modality for PE in 21.3% of patients in first trimester, 19.4% in second trimester, and 6.7% in third trimester. The proportion of postpartum patients confirmed with CTPA (85.5%) was comparable to that of non-pregnant non-postpartum women (83.2%). From the first trimester of pregnancy to postpartum period, there was a linear increase in the proportion of patients with PE diagnosed with CTPA (p = 0.039).

Conclusion

CTPA was the primary modality for confirming PE in all trimesters of pregnancy, although its proportional use was higher in later stages of pregnancy.

Key Points

• Computed tomography pulmonary angiography (CTPA) was the primary modality of diagnosis in all trimesters of pregnancy among patients with confirmed pulmonary embolism, even in the first trimester.

• From the first trimester of pregnancy to postpartum period, there was a linear increase in the proportion of patients with pulmonary embolism who were diagnosed based on CTPA.

• In the postpartum period, use of CTPA as the modality to confirm pulmonary embolism was comparable to non-pregnant patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Abbreviations

CTPA:

Computed tomography pulmonary angiography

IQR:

Interquartile range

pDVT:

Proximal deep vein thrombosis

PE:

Pulmonary embolism

RIETE:

Registro Informatizado Enfermedad TromboEmbolica

SEM:

Standard error of mean

V/Q scan:

Ventilation-perfusion scan

VTE:

Venous thromboembolism

References

  1. James AH, Jamison MG, Brancazio LR, Myers ER (2006) Venous thromboembolism during pregnancy and the postpartum period: incidence, risk factors, and mortality. Am J Obstet Gynecol 194:1311–1315

    Article  Google Scholar 

  2. Elgendy IY, Fogerty A, Blanco-Molina Á et al (2020) Clinical characteristics and outcomes of women presenting with venous thromboembolism during pregnancy and postpartum period: findings from the RIETE Registry. Thromb Haemost 120:1454–1462

    Article  Google Scholar 

  3. Mehdipoor G, Jimenez D, Bertoletti L et al (2020) Patient-level, institutional, and temporal variations in use of imaging modalities to confirm pulmonary embolism. Circ Cardiovasc Imaging 13:e010651

    Article  Google Scholar 

  4. Kirsch J, Brown RKJ, Henry TS et al (2017) ACR Appropriateness Criteria(®) acute chest pain-suspected pulmonary embolism. Journal of the American College of Radiology : JACR 14:S2–s12

    Article  Google Scholar 

  5. Cohen SL, Feizullayeva C, McCandlish JA et al (2020) Comparison of international societal guidelines for the diagnosis of suspected pulmonary embolism during pregnancy. Lancet Haematol 7:e247–e258

    Article  Google Scholar 

  6. Wan T, Skeith L, Karovitch A, Rodger M, Le Gal G (2017) Guidance for the diagnosis of pulmonary embolism during pregnancy: consensus and controversies. Thromb Res 157:23–28

    Article  CAS  Google Scholar 

  7. Tester J, Hammerschlag G, Irving L, Pascoe D, Rees M (2020) Investigation and diagnostic imaging of suspected pulmonary embolism during pregnancy and the puerperium: a review of the literature. J Med Imaging Radiat Oncol 64:505–515

    Article  Google Scholar 

  8. Tomà P, Bartoloni A, Salerno S et al (2019) Protecting sensitive patient groups from imaging using ionizing radiation: effects during pregnancy, in fetal life and childhood. Radiol Med 124:736–744

    Article  Google Scholar 

  9. Ridge CA, McDermott S, Freyne BJ, Brennan DJ, Collins CD, Skehan SJ (2009) Pulmonary embolism in pregnancy: comparison of pulmonary CT angiography and lung scintigraphy. AJR Am J Roentgenol 193:1223–1227

    Article  Google Scholar 

  10. Ridge CA, Mhuircheartaigh JN, Dodd JD, Skehan SJ (2011) Pulmonary CT angiography protocol adapted to the hemodynamic effects of pregnancy. AJR Am J Roentgenol 197:1058–1063

    Article  Google Scholar 

  11. Bikdeli B, Jimenez D, Hawkins M et al (2018) Rationale, design and methodology of the computerized registry of patients with venous thromboembolism (RIETE). Thromb Haemost 118:214–224

    Article  Google Scholar 

  12. van Mens TE, Scheres LJ, de Jong PG, Leeflang MM, Nijkeuter M, Middeldorp S (2017) Imaging for the exclusion of pulmonary embolism in pregnancy. Cochrane Database Syst Rev 1:Cd011053

    PubMed  Google Scholar 

  13. Rubin GD, Leipsic J, Joseph Schoepf U, Fleischmann D, Napel S (2014) CT angiography after 20 years: a transformation in cardiovascular disease characterization continues to advance. Radiology 271:633–652

    Article  Google Scholar 

  14. Tromeur C, van der Pol LM, Le Roux PY et al (2019) Computed tomography pulmonary angiography versus ventilation-perfusion lung scanning for diagnosing pulmonary embolism during pregnancy: a systematic review and meta-analysis. Haematologica 104:176–188

    Article  Google Scholar 

  15. Winer-Muram HT, Boone JM, Brown HL, Jennings SG, Mabie WC, Lombardo GT (2002) Pulmonary embolism in pregnant patients: fetal radiation dose with helical CT. Radiology 224:487–492

    Article  Google Scholar 

  16. Astani SA, Davis LC, Harkness BA, Supanich MP, Dalal I (2014) Detection of pulmonary embolism during pregnancy: comparing radiation doses of CTPA and pulmonary scintigraphy. Nucl Med Commun 35:704–711

    Article  Google Scholar 

  17. van der Pol LM, Tromeur C, Bistervels IM et al (2019) Pregnancy-adapted YEARS algorithm for diagnosis of suspected pulmonary embolism. N Engl J Med 380:1139–1149

    Article  Google Scholar 

  18. Righini M, Robert-Ebadi H, Elias A et al (2018) Diagnosis of pulmonary embolism during pregnancy: a multicenter prospective management outcome study. Ann Intern Med 169:766–773

    Article  Google Scholar 

  19. Zhang W, Shen J, Sun JL (2020) Risk scores, prevention, and treatment of maternal venous thromboembolism. World J Clin Cases 8:2210–2218

    Article  Google Scholar 

  20. Haas S, Ageno W, Weitz JI et al (2019) Anticoagulation therapy patterns for acute treatment of venous thromboembolism in GARFIELD-VTE patients. J Thromb Haemost 17:1694–1706

    Article  CAS  Google Scholar 

  21. Jerjes-Sánchez C, Rodriguez D, Farjat AE et al (2021) Pregnancy-associated venous thromboembolism: insights from GARFIELD-VTE. TH Open 5:e24–e34

    Article  Google Scholar 

  22. Righini M, Robert-Ebadi H, Le Gal G (2017) Diagnosis of acute pulmonary embolism. J Thromb Haemost 15:1251–1261

    Article  CAS  Google Scholar 

  23. Konstantinides SV, Meyer G, Becattini C , et al. (2019) 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): the Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Respir J 54

  24. Leung AN, Bull TM, Jaeschke R et al (2012) American Thoracic Society documents: an official American Thoracic Society/Society of Thoracic Radiology Clinical Practice Guideline--evaluation of suspected pulmonary embolism in pregnancy. Radiology 262:635–646

    Article  Google Scholar 

  25. McLintock C, Brighton T, Chunilal S et al (2012) Recommendations for the diagnosis and treatment of deep venous thrombosis and pulmonary embolism in pregnancy and the postpartum period. Aust N Z J Obstet Gynaecol 52:14–22

    Article  Google Scholar 

  26. Linnemann B, Bauersachs R, Rott H et al (2016) Diagnosis of pregnancy-associated venous thromboembolism - position paper of the Working Group in Women's Health of the Society of Thrombosis and Haemostasis (GTH). Vasa 45:87–101

    Article  Google Scholar 

  27. Chan WS, Rey E, Kent NE et al (2014) Venous thromboembolism and antithrombotic therapy in pregnancy. J Obstet Gynaecol Can 36:527–553

    Article  Google Scholar 

  28. Bajc M, Neilly JB, Miniati M, Schuemichen C, Meignan M, Jonson B (2009) EANM guidelines for ventilation/perfusion scintigraphy : part 2. Algorithms and clinical considerations for diagnosis of pulmonary emboli with V/P(SPECT) and MDCT. Eur J Nucl Med Mol Imaging 36:1528–1538

    Article  CAS  Google Scholar 

  29. Mehdipoor G, Bikdeli B, Prince MR (2019) Diagnosis of suspected pulmonary embolism in pregnancy. N Engl J Med 380:e49

    Article  Google Scholar 

Download references

Acknowledgements

We express our gratitude to Sanofi Spain and LEO PHARMA for supporting this Registry with an unrestricted educational grant. We also thank the RIETE Registry Coordinating Center, S&H Medical Science Service, for their quality control data, and logistic and administrative support, and Prof. Salvador Ortiz, Universidad Autónoma Madrid and Silvia Galindo, both Statistical Advisors in S&H Medical Science Service, for the statistical analysis of the data presented in this paper.

Funding

We express our gratitude to Sanofi Spain for supporting this Registry with an unrestricted educational grant. No additional specific funding support was sought or provided for the current investigation.

Author information

Authors and Affiliations

  1. Department of Medicine, Peconic Bay Medical Center, Northwell Health, Riverhead, NY, USA

    Ghazaleh Mehdipoor

  2. Cardiovascular Research Foundation (CRF), New York, NY, USA

    Ghazaleh Mehdipoor & Behnood Bikdeli

  3. Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain

    David Jimenez

  4. Medicine Department, Universidad de Alcalá, (IRYCIS), Madrid, Spain

    David Jimenez

  5. CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain

    David Jimenez

  6. Service de Médecine Vasculaire et Thérapeutique, Hôpital Nord, CHU de Saint-Etienne and INSERM U1059 SAINBIOSE - CIC 1408, Université Jean-Monnet, Saint-Etienne, France

    Laurent Bertoletti

  7. Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain

    Jorge Del Toro

  8. Department of Internal Medicine, Hospital Universitario La Paz, Madrid, Spain

    Carmen Fernández-Capitán

  9. Department of Vascular Medicine, Hôpital de Rangueil, Toulouse, France

    Alessandra Bura-Riviere

  10. Department of Internal Medicine, Hospital Sierrallana, Santander, Spain

    Cristina Amado

  11. Department of Internal Medicine, Hospital General Universitario de Alicante, Alicante, Spain

    Beatriz Valero

  12. Department of Internal Medicine, Hospital Universitario Reina Sofía, Córdoba, Spain

    Ángeles Blanco-Molina

  13. Department of Pneumonology, Hospital Universitario Virgen del Rocío, Seville, Spain

    Remedios Otero

  14. Department of Clinical and Experimental Medicine, A.O.U Policlinico “G. Martino”, Messina, Italy

    Egidio Imbalzano

  15. Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA

    Ramin Khorasani

  16. Department of Radiology, Weill Cornell Medical College and New York Presbyterian Hospital, New York, USA

    Martin R. Prince

  17. Columbia University College of Physicians and Surgeons, New York, NY, USA

    Martin R. Prince

  18. Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    Behnood Bikdeli

  19. Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA

    Behnood Bikdeli

  20. Department of Internal Medicine, Hospital de Badalona Germans Trias i Pujol, Badalona, Spain

    Manuel Monreal

Authors
  1. Ghazaleh Mehdipoor
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. David Jimenez
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Laurent Bertoletti
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jorge Del Toro
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Carmen Fernández-Capitán
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Alessandra Bura-Riviere
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Cristina Amado
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Beatriz Valero
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Ángeles Blanco-Molina
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Remedios Otero
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Egidio Imbalzano
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Ramin Khorasani
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Martin R. Prince
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Behnood Bikdeli
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Manuel Monreal
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

the RIETE Investigators

Corresponding author

Correspondence to Manuel Monreal.

Ethics declarations

The ethics committees at all participating sites approved the protocol for enrolling patients in RIETE registry for research purposes, and all participating patients or their healthcare proxies provided written informed consent (https://clinicaltrials.gov/ct2/show/NCT02832245).

Guarantor

The scientific guarantor of this publication is Dr. Manuel Monreal.

Conflict of interest

Dr. Bikdeli reports that he is a consulting expert, on behalf of the plaintiff, for litigation related to two specific brand models of IVC filters. The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

A full list of the RIETE investigators is given in the appendix

Supporting Information

ESM 1

(DOC 414 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Mehdipoor, G., Jimenez, D., Bertoletti, L. et al. Imaging modalities for confirming pulmonary embolism during pregnancy: results from a multicenter international study. Eur Radiol 32, 1238–1246 (2022). https://doi.org/10.1007/s00330-021-08161-9

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00330-021-08161-9

Keywords

Search

Navigation