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....................................................................................................... 9 Pulmonary embolism and pregnancy

9.1 Epidemiology and risk factors for

pulmonary embolism in pregnancy Acute PE remains one of the leading causes of maternal death in high-income countries.379,380 For example, in the UK and Ireland, thrombosis and thromboembolism were the most common causes of direct maternal death (death resulting from the pregnancy rather than pre-existing conditions) in the triennium 201315, resulting in 1.13 mortalities per 100 000 maternities (https://www.npeu.ox.ac.uk/mbrrace-uk). VTE risk is higher in pregnant women compared with non-pregnant women of similar age; it increases during pregnancy and reaches a peak during the post-partum period.381 The baseline pregnancy-related risk increases further in the presence of additional VTE risk factors, including in vitro fertilization: in a cross-sectional study derived from a Swedish registry, the HR for VTE following in vitro fertilization was 1.77 (95% CI 1.412.23) overall and 4.22 (95% CI 2.467.20) during the first trimester.382 Other important and common risk factors include prior VTE, obesity, medical comorbidities, stillbirth, pre-eclampsia, post-partum haemorrhage, and caesarean section; documented risk assessment is therefore essential.383 The recommendations provided in these Guidelines are in line with those included in the 2018 ESC Guidelines on the management of cardiovascular diseases during pregnancy.384

9.2 Diagnosis of pulmonary embolism in

pregnancy 9.2.1 Clinical prediction rules and D-dimers Diagnosis of PE during pregnancy can be challenging as symptoms frequently overlap with those of normal pregnancy. The overall prevalence of confirmed PE is low among women investigated for the disease, between 2 and 7%.385388 D-dimer levels continuously increase during pregnancy,389,390 and levels are above the threshold for VTE ‘rule-out’ in almost one-quarter of pregnant women in the third trimester.390 The results of a multinational prospective management study of 441 pregnant women presenting to emergency departments with clinically suspected PE suggest that a diagnostic strategybased on the assessment of clinical probability, D-dimer measurement, CUS, and CTPAmay safely exclude PE in pregnancy.388 In that study, PE exclusion on the basis of a negative D-dimer result (without imaging) was possible in 11.7% of the 392 women with a non-high pre-test probability (Geneva) score, a rate that was reduced to 4.2% in the third trimester.388 A further prospective management study evaluated a combination of a pregnancy-adapted YEARS algorithm with D-dimer levels in 498 women with suspected PE during pregnancy. PE was ruled out without CTPA in women deemed to be at low PE risk according to the combination of the algorithm and D-dimer results. At 3 months, only one woman with PE excluded on the basis of the algorithm developed a popliteal DVT (0.21%, 95% CI 0.041.2) and no women developed PE.391

9.2.2 Imaging tests A proposed algorithm for the investigation of suspected PE in women who are pregnant, or <_6 weeks post-partum, is shown in Figure 7. Both maternal and foetal radiation exposure are low using modern imaging techniques (Table 12).385,392398 For V/Q scans and CTPA, foetal radiation doses are well below the threshold associated with foetal radiation complications (which is 50100 mSv).399,400 In the past, CTPA has been reported to cause high radiation exposure to the breast;395,401 however, CT technology has evolved, and several techniques can now reduce radiation exposure without compromising image quality. These

8.6 Recommendations for the regimen and the duration of anticoagulation after pulmonary embolism in patients with active cancer

Recommendations Classa Levelb

For patients with PE and cancer, weight-adjusted subcutaneous LMWH should be considered for the first 6 months over VKAs.360363 IIa A Edoxaban should be considered as an alternative to weight-adjusted subcutaneous LMWH in patients without gastrointestinal cancer.366 IIa B Rivaroxaban should be considered as an alternative to weight-adjusted subcutaneous LMWH in patients without gastrointestinal cancer.367 IIa C For patients with PE and cancer, extended anticoagulation (beyond the first 6 months)c should be considered for an indefinite period or until the cancer is cured.378 IIa B In patients with cancer, management of incidental PE in the same manner as symptomatic PE should be considered, if it involves segmental or more proximal branches, multiple subsegmental vessels, or a single subsegmental vessel in association with proven DVT.376,377 IIa B

DVT = deep vein thrombosis; LMWH = low-molecular weight heparin; PE = pulmonary embolism; VKAs = vitamin K antagonists. aClass of recommendation. bLevel of evidence. cRefer to Supplementary Data Table 9 for further guidance on therapeutic decisions after the first 6 months. Downloaded from academic.oup.com/eurheartj/article/41/4/543/5556136 by guest on 07 October 2026