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Correspondence |

Choice of Imaging Studies in Acutely Ill Pregnant Women FREE TO VIEW

Tabassum Firoz, MD; Margaret A. Miller, MD; Ghada Bourjeily, MD
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

CORRESPONDENCE TO: Ghada Bourjeily, MD, 146 W River St, Ste 11C, Providence, RI 02904


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;149(1):290-291. doi:10.1016/j.chest.2015.10.055
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The case report in CHEST (June 2015) by Daglian and Patrawalla highlights the challenge of emergency care of the obstetric patient. While the innovative use of lung ultrasonography for rapid and accurate diagnosis in respiratory failure is promising and could be particularly beneficial to the pregnant patient, we would like to suggest redirecting strategies for selecting diagnostic studies in complicated pregnant patients to focus on timely diagnosis and avoiding undue concerns about safety risk.

As in the nonpregnant population, lung ultrasonography would be most attractive if it has good positive and negative predictive value, is safe, and there is expertise with using and interpreting it locally. It is common for providers to withhold tests in a pregnant patient due to presumed risks to the fetus. This may lead to delays in diagnosis as well as diagnostic and therapeutic errors, resulting in similar or worse harm. In this case report, chest radiograph was initially withheld, and pulmonary embolism (PE) was excluded based on Doppler testing of the legs alone. Though PE was unlikely in this patient, clinicians had a high enough suspicion to empirically initiate anticoagulation treatment, bypassing diagnostic testing. Such practices are considered substandard care in the nonpregnant population; the same should apply to pregnancy.

In the United States, reducing maternal mortality and morbidity remains a challenge, with the maternal mortality ratio doubling between 1990 and 2013 in part due to inconsistent obstetric practice across hospitals. Peripartum VTE, still one of the leading causes of maternal deaths in the United States, has been identified as one of the priority bundles by the National Partnership for Maternal Safety. By standardizing care through the use of evidence-based national guidelines, we can decrease PE-related maternal deaths as seen in the United Kingdom.

Current guidelines recommend that in pregnant women with suspected PE and no signs and symptoms of DVT (as in this case), studies of the pulmonary vasculature should not be delayed., This includes chest radiograph followed by either a CT angiogram or a ventilation perfusion scan. While the risk of teratogenicity requires a radiation threshold of at least 5 rad, a CT angiogram or chest radiograph exposes the fetus to very small amounts of radiation (0.01 rad and 0.0002 rad, respectively). Lung ultrasonography may prove to be a valuable tool, however, it should not replace our current standard of care in pregnant women until it becomes fully validated both in and outside of pregnancy.

References

Daglian D.M. .Patrawalla P. . Pregnant patient with progressive hypoxemic respiratory failure. Chest. 2015;147:e205-e207 [PubMed]journal. [CrossRef] [PubMed]
 
Agrawal P. . Maternal mortality and morbidity in the United States of America. Bull World Health Organ. 2015;93:135- [PubMed]journal. [CrossRef] [PubMed]
 
D’Alton M.E. .Main E.K. .Menard M.K. .Levy B.S. . The National Partnership for Maternal Safety. Obstet Gynecol. 2014;123:973-977 [PubMed]journal. [CrossRef] [PubMed]
 
Lewis G. . Saving Mothers’ Lives: the continuing benefits for maternal health from the United Kingdom (UK) Confidential Enquires into Maternal Deaths. Semin Perinatol. 2012;36:19-26 [PubMed]journal. [CrossRef] [PubMed]
 
Pulmonary Embolism in Pregnancy. Diagnosis and Treatment (7th Draft 4-5-2013). American College of Obstetricians and Gynecologists website.http://www.acog.org/∼/media/Districts/District VIII/PulmonaryEmbolismPregnancy.pdf?dmc=1. Accessed July 1, 2015.
 
Leung A.N. .Bull T.M. .Jaeschke R. . ATS/STR Committee on Pulmonary Embolism in Pregnancyet al An official American Thoracic Society/Society of Thoracic Radiology clinical practice guideline: evaluation of suspected pulmonary embolism in pregnancy. Am J Respir Crit Care Med. 2011;184:1200-1208 [PubMed]journal. [CrossRef] [PubMed]
 
ACOG Committee on Obstetric Practice ACOG Committee Opinion. Number 299, September 2004 (replaces No. 158, September 1995). Guidelines for diagnostic imaging during pregnancy. Obstet Gynecol. 2004;104:647-651 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

Daglian D.M. .Patrawalla P. . Pregnant patient with progressive hypoxemic respiratory failure. Chest. 2015;147:e205-e207 [PubMed]journal. [CrossRef] [PubMed]
 
Agrawal P. . Maternal mortality and morbidity in the United States of America. Bull World Health Organ. 2015;93:135- [PubMed]journal. [CrossRef] [PubMed]
 
D’Alton M.E. .Main E.K. .Menard M.K. .Levy B.S. . The National Partnership for Maternal Safety. Obstet Gynecol. 2014;123:973-977 [PubMed]journal. [CrossRef] [PubMed]
 
Lewis G. . Saving Mothers’ Lives: the continuing benefits for maternal health from the United Kingdom (UK) Confidential Enquires into Maternal Deaths. Semin Perinatol. 2012;36:19-26 [PubMed]journal. [CrossRef] [PubMed]
 
Pulmonary Embolism in Pregnancy. Diagnosis and Treatment (7th Draft 4-5-2013). American College of Obstetricians and Gynecologists website.http://www.acog.org/∼/media/Districts/District VIII/PulmonaryEmbolismPregnancy.pdf?dmc=1. Accessed July 1, 2015.
 
Leung A.N. .Bull T.M. .Jaeschke R. . ATS/STR Committee on Pulmonary Embolism in Pregnancyet al An official American Thoracic Society/Society of Thoracic Radiology clinical practice guideline: evaluation of suspected pulmonary embolism in pregnancy. Am J Respir Crit Care Med. 2011;184:1200-1208 [PubMed]journal. [CrossRef] [PubMed]
 
ACOG Committee on Obstetric Practice ACOG Committee Opinion. Number 299, September 2004 (replaces No. 158, September 1995). Guidelines for diagnostic imaging during pregnancy. Obstet Gynecol. 2004;104:647-651 [PubMed]journal. [CrossRef] [PubMed]
 
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