Vinson David R, Somers Madeline J, Qiao Edward, Campbell Aidan R, Heringer Grace V, Florio Cole J, Zekar Lara, Middleton Cydney E, Woldemariam Sara T, Gupta Nachiketa, Poth Luke S, Reed Mary E, Roubinian Nareg H, Raja Ali S, Sperling Jeffrey D
The Permanente Medical Group, Pleasanton, California, USA.
Kaiser Permanente Northern California Division of Research, Pleasanton, California, USA.
Acad Emerg Med. 2025 Mar;32(3):260-273. doi: 10.1111/acem.15045. Epub 2024 Nov 17.
Nonconsent to pulmonary vascular (or advanced) imaging for suspected pulmonary embolism (PE) in pregnancy can delay diagnosis and treatment, increasing risk of adverse outcomes. We sought to understand factors associated with consent and understand outcomes after nonconsent.
This retrospective cohort study was undertaken across 21 community hospitals from October 1, 2021, through March 31, 2023. We included gravid patients undergoing diagnostics for suspected PE who were recommended advanced imaging. The primary outcome was verbal consent to advanced imaging. Diagnostic settings were nonobstetric (99% emergency departments [EDs]) and obstetrics (labor and delivery and outpatient clinics). Using quasi-Poisson regression, we calculated adjusted relative risks (aRRs) of consenting with 95% confidence intervals (CIs). We also reported symptom resolution and delayed imaging at follow-up and 90-day PE outcomes.
Imaging was recommended for 405 outpatients: median age was 30.5 years; 50% were in the third trimester. Evaluation was more common in nonobstetric (83%) than obstetric settings (17%). Overall, 314 (78%) agreed to imaging and 91 (22%) declined imaging. Consenting was more prevalent in obstetric settings compared with nonobstetric settings: 99% versus 73% (p < 0.001). When adjusted for demographic and clinical variables, including pretest probability, only obstetric setting was independently associated with consenting: aRR 1.26 (95% CI 1.09-1.44). Seventy-nine (87%) patients declining imaging had 30-day follow-up. Eight of 12 who reported persistent or worsening symptoms on follow-up were again recommended advanced imaging and consented. Imaging was negative. None who initially declined imaging were diagnosed with PE or died within 90 days.
One in five gravid patients suspected of PE declined advanced imaging, more commonly in nonobstetric (principally ED) settings than obstetric settings. Patients symptomatic on follow-up responded favorably to subsequent imaging recommendations without 90-day outcomes. Improving the communication and documentation of informed consent and securing close follow-up for nonconsenters may mitigate risks of missed and delayed PE diagnosis.
对于疑似妊娠合并肺栓塞（PE）的患者，若不同意进行肺血管（或高级）成像检查，可能会延误诊断和治疗，增加不良结局的风险。我们旨在了解与同意检查相关的因素，并了解不同意检查后的结局。
这项回顾性队列研究于2021年10月1日至2023年3月31日在21家社区医院进行。我们纳入了接受疑似PE诊断且被建议进行高级成像检查的孕妇。主要结局是对高级成像检查的口头同意。诊断场所为非产科（99%为急诊科[ED]）和产科（分娩室和门诊诊所）。使用准泊松回归，我们计算了同意检查的调整相对风险（aRRs）及95%置信区间（CIs）。我们还报告了随访时症状缓解情况、延迟成像情况以及90天PE结局。
405名门诊患者被建议进行成像检查：中位年龄为30.5岁；50%处于孕晚期。非产科场所（83%）的评估比产科场所（17%）更常见。总体而言，314名（78%）患者同意成像检查，91名（22%）患者拒绝成像检查。与非产科场所相比，产科场所同意检查的情况更为普遍：分别为99%和73%（p < 0.001）。在对包括预检概率在内的人口统计学和临床变量进行调整后，只有产科场所与同意检查独立相关：aRR为1.26（95% CI 1.09 - 1.44）。79名（87%）拒绝成像检查的患者进行了30天随访。12名随访时报告症状持续或加重的患者中有8名再次被建议进行高级成像检查并同意。成像检查结果为阴性。最初拒绝成像检查的患者在90天内均未被诊断为PE或死亡。
五分之一疑似PE的孕妇拒绝进行高级成像检查，在非产科（主要是急诊科）场所比产科场所更常见。随访时有症状的患者对后续成像检查建议反应良好，且90天内无不良结局。改善知情同意的沟通和记录，并确保对不同意检查的患者进行密切随访，可能会降低漏诊和延迟诊断PE的风险。
