Evaluation and Initial Management of Pulmonary Embolism during Pregnancy and the Puerperium

Abstract

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.