1. PE in Pregnancy: What Imaging? What Drugs?
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Consult Guys
PE in Pregnancy: What Imaging? What Drugs?
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3. 35 yo morbidly obese, female. Lungs clear without crackles
I am an ED physician in Northeastern Pennsylvania. I saw a You Tube show you did last year and I figured I would take a chance and call you guys to get some input on a case.
Dear Consult Guys,
A 35-year-old woman 26 weeks pregnant is in my ED with a 48 hour history of increasing SOB, pleuritic chest pain and chest heaviness “like someone sitting on my chest”. She had no leg pains. She is taking prenatal vitamins and has no allergies to medications. Her past medical history is negative. She has had 2 previous C-Sections without complications. She is a non-smoker and does no use drugs or alcohol. There is no family history of venous thromboembolism.
Physical Examination showed BP 124/90, P 112, R 24, T 98.8, Wt 230lbs, BMI 45, POx 98%
35 yo morbidly obese, female.
Lungs clear without crackles
Heart 112/min, regular rhythm, S1 and S2 normal, no murmurs
Abdomen obese, active bowel sounds
Labs: D-dimer 1800, Troponins negative,nT ProBNP 617, Hgb 11.5/ Hct 34.6, Plts 180K, PT and PTT normal
Legs soft and non-tender, no edema
ECG: sinus tachycardia, rate 108
I want to order a chest CTA with contrast.
I have 2 questions for you guys.
What is the fetal and maternal risk from a chest CTA?
If she has a PE, what are the best treatment options for managing a pregnant patient with PE?
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4. Royal College of Obstetricians & Gynaecologists
Women presenting with symptoms and signs of an acute PE should have an electrocardiogram (ECG) and a chest X-ray (CXR) performed.
In women with suspected PE without symptoms and signs of DVT, a ventilation/perfusion (V/Q) lung scan or CT pulmonary angiogram should be performed.
D-dimer testing is NOT recommended in pregnant patients.
Royal College of Obstetricians and Gynaecologists. Thromboembolic Disease in Pregnancy and the Puerperium: Acute Management. Green-top Guideline No. 37b. April 2015.

5. Anticoagulation UFH Treatment of PE in Pregnancy
Heparin does not cross the placental barrier.
80 units/kg, Bolus
18 units/kg/h, Infusion
Adjust to therapeutic PTT range
Category C
Animal reproduction studies have not been conducted with heparin sodium. It is also not known whether heparin sodium can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity, but potential benefits may warrant use of the drug in pregnant women despite potential risks.
Royal College of Obstetricians and Gynaecologists. Thromboembolic Disease in Pregnancy and the Puerperium: Acute Management. Green-top Guideline No. 37b. April 2015.

6. LMWH Treatment of PE in Pregnancy
LMWH (enoxaparin, dalteparin) does not cross the placenta and is not expected to result in fetal exposure to the drug.
Enoxaparin
1 mg/kg, subcutaneous, Q12h
Dalteparin
200 units/kg once daily (maximum dose:
units/day) 
Category B
Animal reproduction studies have failed to demonstrate a risk to the fetus and
there are no adequate and well-controlled studies in pregnant women.
Human data from a retrospective cohort study, which included 693 live births,
suggest that LMWH does not increase the risk of major developmental abnormalities.

7. Thrombolysis
Alteplase and tenecteplase do not cross the placenta, and studies on rats and rabbits did not find teratogenicity.
Relative contraindication for its use. Alteplase or tenecteplase should not be withheld in pregnancy
Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, et al; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Leung AN, Bull TM, Jaeschke R, Lockwood CJ, Boiselle PM, Hurwitz LM, et al; ATS/STR Committee on Pulmonary Embolism in Pregnancy. 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: [PMID: ]

8. Thrombolysis
Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, et al; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Leung AN, Bull TM, Jaeschke R, Lockwood CJ, Boiselle PM, Hurwitz LM, et al; ATS/STR Committee on Pulmonary Embolism in Pregnancy. 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: [PMID: ]

9. LMWH Treatment of PE in Pregnancy
LMWH (enoxaparin, dalteparin) does not cross the placenta and is not expected to result in fetal exposure to the drug.
Discontinue 24 h prior to delivery
Restart 24 h after delivery
Continue LMWH to complete 12 weeks Rx
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