Fitzsimmons Jack, Hart Laura, Oliver Emily, Mulla Wadia
Department of Obstetrics, Gynecology and Reproductive Sciences, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania.
Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania.
Am J Perinatol. 2024 May;41(S 01):e2307-e2312. doi: 10.1055/a-2112-8049. Epub 2023 Jun 19.
Pulmonary embolism (PE) is a significant cause of obstetric morbidity and mortality. However, overdiagnosis related to excessive use of diagnostic testing is also associated with long-term major health issues, including impact on future pregnancies and subsequent health care. Accurate diagnosis of PE depends on the knowledge of prevalence of PE in the pregnant population, the a priori probability of a PE based on specific findings in a given patient, and understanding of the accuracy of computed tomography pulmonary angiography (CTPA), the dominant diagnostic modality employed for this diagnosis. Venous thromboembolism is widely considered to be more common in pregnancy. However, this term includes both deep venous thrombosis as well as PE. While the former appears to be more common, published data on the prevalence of PE in pregnancy show little or no increase relative to the general population. Given the published data on the sensitivity and specificity of CTPA, a positive reading is more likely to be a false positive unless the probability of a PE in a given patient is at least 5% (a 200-fold increase from baseline). Doubling the probability to 10% (a 400-fold increase) only improves the positive predictive value to approximately 67%. Strategies to refine the a priori probability of a PE in a given patient are detailed, including scoring systems and D-dimer measurements. A careful history and physical examination and thoughtful development of a differential diagnosis are key elements of clinical practice and should include both the likelihood of each possible diagnosis and the accuracy of diagnostic modalities. This approach should precede the application of a given algorithm. Such a structured approach can decrease utilization and limit false positive diagnoses without increasing morbidity or mortality. KEY POINTS: · Incidence of PE is lower than assumed.. · Incidence is critical for assessing predictive value of a test.. · Computed tomography angiography is likely overused in pregnancy.. · Clinical scoring and D-dimer have a role in PE diagnosis..
肺栓塞（PE）是产科发病和死亡的重要原因。然而，与过度使用诊断检测相关的过度诊断也与长期的重大健康问题有关，包括对未来妊娠和后续医疗保健的影响。PE的准确诊断取决于对孕妇中PE患病率的了解、基于特定患者特定发现的PE先验概率，以及对计算机断层扫描肺动脉造影（CTPA）准确性的理解，CTPA是用于此诊断的主要诊断方式。静脉血栓栓塞被广泛认为在妊娠中更为常见。然而，这个术语包括深静脉血栓形成以及PE。虽然前者似乎更常见，但关于妊娠中PE患病率的已发表数据显示，与普通人群相比几乎没有增加或没有增加。根据已发表的关于CTPA敏感性和特异性的数据，除非给定患者中PE的概率至少为5%（比基线增加200倍），否则阳性结果更可能是假阳性。将概率加倍至10%（增加400倍）只会将阳性预测值提高到约67%。详细介绍了提高给定患者中PE先验概率的策略，包括评分系统和D-二聚体测量。仔细的病史和体格检查以及精心制定鉴别诊断是临床实践的关键要素，应包括每种可能诊断的可能性和诊断方式的准确性。这种方法应先于应用给定的算法。这种结构化方法可以减少使用并限制假阳性诊断，而不会增加发病率或死亡率。要点：·PE的发病率低于预期。·发病率对于评估检测的预测价值至关重要。·计算机断层扫描血管造影在妊娠中可能被过度使用。·临床评分和D-二聚体在PE诊断中发挥作用。
