Diagnostic management of suspected acute pulmonary embolism in the postpartum period

Background Pregnancy and the postpartum period increase the risk of venous thromboembolism including pulmonary embolism (PE), which is an important cause of maternal morbidity and mortality. While diagnostic strategies for suspected PE in pregnancy have evolved, postpartum patients remain underrepresented in research. Objectives This study evaluated diagnostic strategies and the incidence of PE among postpartum patients presenting to an acute care setting with suspected PE, using data from a previously published individual patient data meta-analysis. Methods We analyzed 201 postpartum patients from 6 studies included in the individual patient data meta-analysis. Primary outcomes were PE incidence and a description of the diagnostic tests used. Secondary outcomes included the performance of retrospectively calculated clinical decision rules (CDRs) including the revised Geneva score, pregnancy-adapted Geneva (PAG) score, and pulmonary embolism rule-out criteria (PERC), in combination with D-dimer testing and imaging. Results Among 201 postpartum patients with suspected PE, the incidence was 6.0% (95% CI, 2.9%-12.3%). The revised Geneva and PERC CDRs performed similarly to previously published data. Notably, 29% (29/100, 95% CI, 21%-39%) of postpartum patients had a negative D-dimer result, and none of those with a negative result were diagnosed with PE, regardless of the CDR used. Conclusion The observed PE incidence of 6.0% in this postpartum cohort underscores the need for evidence-based diagnostic pathways for physicians. Given that 29% of patients had a negative D-dimer and none were diagnosed with PE, diagnostic algorithms incorporating D-dimer testing could be applied in postpartum evaluations.