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Imaging for the exclusion of pulmonary embolism in pregnancy.
Cochrane Database Syst Rev. 2017 01 26; 1:CD011053.CD

Abstract

BACKGROUND

Pulmonary embolism is a leading cause of pregnancy-related death. An accurate diagnosis in pregnant patients is crucial to prevent untreated pulmonary embolism as well as unnecessary anticoagulant treatment and future preventive measures. Applied imaging techniques might perform differently in these younger patients with less comorbidity and altered physiology, who largely have been excluded from diagnostic studies.

OBJECTIVES

To determine the diagnostic accuracy of computed tomography pulmonary angiography (CTPA), lung scintigraphy and magnetic resonance angiography (MRA) for the diagnosis of pulmonary embolism during pregnancy.

SEARCH METHODS

We searched MEDLINE and Embase until July 2015. We used included studies as seeds in citations searches and in 'find similar' functions and searched reference lists. We approached experts in the field to help us identify non-indexed studies.

SELECTION CRITERIA

We included consecutive series of pregnant patients suspected of pulmonary embolism who had undergone one of the index tests (computed tomography (CT) pulmonary angiography, lung scintigraphy or MRA) and clinical follow-up or pulmonary angiography as a reference test.

DATA COLLECTION AND ANALYSIS

Two review authors performed data extraction and quality assessment. We contacted investigators of potentially eligible studies to obtain missing information. In the primary analysis, we regarded inconclusive index test results as a negative reference test, and treatment for pulmonary embolism after an inconclusive index test as a positive reference test.

MAIN RESULTS

We included 11 studies (four CTPA, five lung scintigraphy, two both) with a total of 695 CTPA and 665 lung scintigraphy results. Lung scintigraphy was applied by different techniques. No MRA studies matched our inclusion criteria.Overall, risk of bias and concerns regarding applicability were high in all studies as judged in light of the review research question, as was heterogeneity in study methods. We did not undertake meta-analysis. All studies used clinical follow-up as a reference standard, none in a manner that enabled reliable identification of false positives. Sensitivity and negative predictive value were therefore the only valid test accuracy measures.The median negative predictive value for CTPA was 100% (range 96% to 100%). Median sensitivity was 83% (range 0% to 100%).The median negative predictive value for lung scintigraphy was 100% (range 99% to 100%). Median sensitivity was 100% (range 0% to 100%).The median frequency of inconclusive results was 5.9% (range 0.9% to 36%) for CTPA and 4.0% (range 0% to 23%) for lung scintigraphy. The overall median prevalence of pulmonary embolism was 3.3% (range 0.0% to 8.7%).

AUTHORS' CONCLUSIONS

Both CTPA and lung scintigraphy seem appropriate for exclusion of pulmonary embolism during pregnancy. However, the quality of the evidence mandates cautious adoption of this conclusion. Important limitations included poor reference standards, necessary assumptions in the analysis regarding inconclusive test results and the inherent inability of included studies to identify false positives. It is unclear which test has the highest accuracy. There is a need for direct comparisons between diagnostic methods, including MR, in prospective randomized diagnostic studies.

Authors+Show Affiliations

Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, Amsterdam, Netherlands, 1105 AZ.Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, Amsterdam, Netherlands, 1105 AZ.Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, Amsterdam, Netherlands, 1105 AZ.Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, P.O. Box 22700, Amsterdam, Netherlands, 1100 DE.Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, Amsterdam, Netherlands, 1105 AZ. Department of Internal Medicine, University Medical Centre Utrecht, Heidelberglaan 100, Utrecht, Netherlands, 3584 CX.Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, Amsterdam, Netherlands, 1105 AZ.

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't
Review
Systematic Review

Language

eng

PubMed ID

28124411

Citation

van Mens, Thijs E., et al. "Imaging for the Exclusion of Pulmonary Embolism in Pregnancy." The Cochrane Database of Systematic Reviews, vol. 1, 2017, p. CD011053.
van Mens TE, Scheres LJ, de Jong PG, et al. Imaging for the exclusion of pulmonary embolism in pregnancy. Cochrane Database Syst Rev. 2017;1:CD011053.
van Mens, T. E., Scheres, L. J., de Jong, P. G., Leeflang, M. M., Nijkeuter, M., & Middeldorp, S. (2017). Imaging for the exclusion of pulmonary embolism in pregnancy. The Cochrane Database of Systematic Reviews, 1, CD011053. https://doi.org/10.1002/14651858.CD011053.pub2
van Mens TE, et al. Imaging for the Exclusion of Pulmonary Embolism in Pregnancy. Cochrane Database Syst Rev. 2017 01 26;1:CD011053. PubMed PMID: 28124411.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Imaging for the exclusion of pulmonary embolism in pregnancy. AU - van Mens,Thijs E, AU - Scheres,Luuk Jj, AU - de Jong,Paulien G, AU - Leeflang,Mariska Mg, AU - Nijkeuter,Mathilde, AU - Middeldorp,Saskia, Y1 - 2017/01/26/ PY - 2017/1/27/pubmed PY - 2017/4/22/medline PY - 2017/1/27/entrez SP - CD011053 EP - CD011053 JF - The Cochrane database of systematic reviews JO - Cochrane Database Syst Rev VL - 1 N2 - BACKGROUND: Pulmonary embolism is a leading cause of pregnancy-related death. An accurate diagnosis in pregnant patients is crucial to prevent untreated pulmonary embolism as well as unnecessary anticoagulant treatment and future preventive measures. Applied imaging techniques might perform differently in these younger patients with less comorbidity and altered physiology, who largely have been excluded from diagnostic studies. OBJECTIVES: To determine the diagnostic accuracy of computed tomography pulmonary angiography (CTPA), lung scintigraphy and magnetic resonance angiography (MRA) for the diagnosis of pulmonary embolism during pregnancy. SEARCH METHODS: We searched MEDLINE and Embase until July 2015. We used included studies as seeds in citations searches and in 'find similar' functions and searched reference lists. We approached experts in the field to help us identify non-indexed studies. SELECTION CRITERIA: We included consecutive series of pregnant patients suspected of pulmonary embolism who had undergone one of the index tests (computed tomography (CT) pulmonary angiography, lung scintigraphy or MRA) and clinical follow-up or pulmonary angiography as a reference test. DATA COLLECTION AND ANALYSIS: Two review authors performed data extraction and quality assessment. We contacted investigators of potentially eligible studies to obtain missing information. In the primary analysis, we regarded inconclusive index test results as a negative reference test, and treatment for pulmonary embolism after an inconclusive index test as a positive reference test. MAIN RESULTS: We included 11 studies (four CTPA, five lung scintigraphy, two both) with a total of 695 CTPA and 665 lung scintigraphy results. Lung scintigraphy was applied by different techniques. No MRA studies matched our inclusion criteria.Overall, risk of bias and concerns regarding applicability were high in all studies as judged in light of the review research question, as was heterogeneity in study methods. We did not undertake meta-analysis. All studies used clinical follow-up as a reference standard, none in a manner that enabled reliable identification of false positives. Sensitivity and negative predictive value were therefore the only valid test accuracy measures.The median negative predictive value for CTPA was 100% (range 96% to 100%). Median sensitivity was 83% (range 0% to 100%).The median negative predictive value for lung scintigraphy was 100% (range 99% to 100%). Median sensitivity was 100% (range 0% to 100%).The median frequency of inconclusive results was 5.9% (range 0.9% to 36%) for CTPA and 4.0% (range 0% to 23%) for lung scintigraphy. The overall median prevalence of pulmonary embolism was 3.3% (range 0.0% to 8.7%). AUTHORS' CONCLUSIONS: Both CTPA and lung scintigraphy seem appropriate for exclusion of pulmonary embolism during pregnancy. However, the quality of the evidence mandates cautious adoption of this conclusion. Important limitations included poor reference standards, necessary assumptions in the analysis regarding inconclusive test results and the inherent inability of included studies to identify false positives. It is unclear which test has the highest accuracy. There is a need for direct comparisons between diagnostic methods, including MR, in prospective randomized diagnostic studies. SN - 1469-493X UR - https://www.unboundmedicine.com/medline/citation/28124411/Imaging_for_the_exclusion_of_pulmonary_embolism_in_pregnancy_ L2 - https://doi.org/10.1002/14651858.CD011053.pub2 DB - PRIME DP - Unbound Medicine ER -