The DiPEP study: an observational study of the diagnostic accuracy of clinical assessment, D-dimer and chest x-ray for suspected pulmonary embolism in pregnancy and postpartum.

OBJECTIVE: To identify clinical features associated with pulmonary embolism (PE) diagnosis and determine the accuracy of decision rules and D-dimer for diagnosing suspected PE in pregnant/postpartum women DESIGN: Observational cohort study augmented with additional cases. SETTING: Emergency departments and maternity units at eleven prospectively recruiting sites and maternity units in the United Kingdom Obstetric Surveillance System (UKOSS) POPULATION: 324 pregnant/postpartum women with suspected PE and 198 pregnant/postpartum women with diagnosed PE METHODS: We recorded clinical features, elements of clinical decision rules, D-dimer measurements, imaging results, treatments and adverse outcomes up to 30 days MAIN OUTCOME MEASURES: Women were classified as having PE on the basis of imaging, treatment and adverse outcomes by assessors blind to clinical features and D-dimer. Primary analysis was limited to women with conclusive imaging to avoid work-up bias. Secondary analyses included women with clinically diagnosed or ruled out PE. RESULTS: The only clinical features associated with PE on multivariate analysis were age (odds ratio 1.06; 95% confidence interval 1.01-1.11), previous thrombosis (3.07; 1.05-8.99), family history of thrombosis (0.35; 0.14-0.90), temperature (2.22; 1.26-3.91), systolic blood pressure (0.96; 0.93-0.99), oxygen saturation (0.87; 0.78-0.97) and PE-related chest x-ray abnormality (13.4; 1.39-130.2). Clinical decision rules had areas under the receiver-operator characteristic curve ranging from 0.577 to 0.732 and no clinically useful threshold for decision-making. Sensitivities and specificities of D-dimer were 88.4% and 8.8% using a standard threshold and 69.8% and 32.8% using a pregnancy-specific threshold. CONCLUSIONS: Clinical decision rules and D-dimer should not be used to select pregnant or postpartum women with suspected PE for further investigation. Clinical features and chest x-ray appearances may have counter-intuitive associations with PE in this context. TWEETABLE ABSTRACT: Clinical decision rules and D-dimer are not helpful for diagnosing pregnant/postpartum women with suspected PE.

Promoting fetal stabilization during maternal hemodynamic instability or respiratory insufficiency.

Fetal oxygenation is primarily determined by maternal oxygenation and uterine blood flow. Several physiologic adaptations during pregnancy support uteroplacental perfusion and, thus, fetal oxygenation. However, the physiologic changes required to sustain the metabolic demands of pregnancy may also predispose the parturient to decompensation when critical illness is superimposed upon pregnancy. In general, the critically ill gravid woman is treated similarly to the nonpregnant adult, with the exception of accomodating the physiologic changes of pregnancy and evaluating fetal well-being. An overview of the physiology of fetal oxygenation, impact of critical care interventions upon the fetus, and evaluation of the fetus is provided.

[Evaluation of the intrauterine fetus in hypertension--biochemical assessment of amniotic fluid. IV. Ions]. / Ocena stanu wewnatrzmacicznego plodu w nadcisnieniu tetniczym krwi--poprzez badania biochemiczne plynu owodniowego. IV. Jony.

Sixty two samples of amniotic fluid, collected by ultrasound guided amniocentesis, were submitted to biochemical investigation including 31 samples from women with pregnancy complicated by hypertension (studied group) and 31 samples deriving from healthy pregnant women (control group with). Both investigated and control groups consisted of pregnant women with the same gestational age of 37 +/- 2 weeks (34-40 weeks). The following ions were measured: NH4+, K+, Na+, Cl-, Mg++, total Ca, Ca++ and inorganic phosphorus (Pi). The ionic composition of amniotic fluid deriving from women with pregnancy complicated by hypertension was normal. The regular concentration of NH4+ ions in amniotic fluids of a studied group may suggest kidneys of the fetuses in pregnancy complicated by hypertension were as mature as in the normal pregnancy within the same gestational age.

[Evaluation of fetal condition in pregnancy complicated by hypertension--biochemical assessment of amniotic fluid. I. Protein and lipid components and kidney maturation]. / Ocena stanu wewnatrzmacicznego plodu w nadcisnieniu tetniczym krwi--poprzez badania biochemiczne plynu owodniowego. I. Skladniki bialkowe, lipidowe i dojrzalosci nerek.

Sixty two samples of amniotic fluid were submitted to biochemical investigation including 31 samples from women with pregnancy complicated by hypertension (studied group with mean blood pressure 165 +/- 15/95 +/- 5 mmHg) and 31 samples deriving from healthy pregnant women (control group with mean blood pressure 118 +/- 10/74 +/- +/- 9 mmHg). In the studied group pregnancy induced hypertension, primary hypertension and nephrogenic hypertension scored 58%, 32% and 10% of cases respectively. Both investigated and control groups consisted of pregnant women with the same gestational age of 37 +/- 2 weeks (34-40 weeks). The following parameters of amniotic fluid were measured: 1) total protein, 2) albumin, 3) beta-lipoprotein, 4) cholesterol, 5) uric acid, 6) urea, 7) creatinine. Micromethods were used. Amniotic fluid deriving from women with pregnancy complicated by hypertension showed decreased concentrations of total protein, albumin and beta-lipoprotein. In pregnancy complicated by hypertension kidneys of the fetuses were estimated to be as mature as in the normal pregnancy within the same gestational age.

[Evaluation of fetal condition in pregnancy complicated by hypertension--biochemical assessment of amniotic fluid. III. Acid-base balance]. / Ocena stanu wewnatrzmacicznego plodu w nadcisnieniu tetniczym krwi--poprzez badania biochemiczne plynu owodniowego. III. Równowaga kwasowo-zasadowa.

Sixty two samples of amniotic fluid, collected by ultrasound guided amniocentesis, were submitted to biochemical investigation including 31 samples from women with pregnancy complicated by hypertension (studied group) and 31 samples deriving from healthy pregnant women (control group with). The following parameters of acid-base balance were measured in amniotic fluids of both groups: pH, pCO2, base deficiency, standard HCO3 and total CO2. Corning device type 168 was used. Distinct metabolic-respiratory acidosis was present in amniotic fluids of studied group showing the decrease of a pH, pO2, standard HCO3 values and an increase of CO2 values and base deficiency. Authors believe in pregnancy complicated by hypertension biochemical environment of intrauterine fetal development with regard to acid-base balance is highly unfavourable.

Toxemia of pregnancy: assessment of fetal distress by urinary estriol and circulating human placental lactogen and alpha-fetoprotein levels.

The efficacy of three biochemical methods for the detection of fetal distress was assessed in a prospective study of 224 singleton pregnancies complicated by toxemia. Fetal distress was diagnosed in 65 cases (29 per cent). Abnormally low urinary estriol (E3) excretion pointed out 63 per cent, low serum levels of human placental lactogen (HPL) 27 per cent, and elevated maternal serum alpha fetoprotein (AFP) 10 per cent of distressed fetuses. The efficacy of each test increased with the severity of maternal disease. The frequencies of false pathologic levels were: E3 19 per cent, HPL 0 per cent, and AFP 1 per cent of the cases with a normal fetal outcome. Although E3 was by far the most effective marker, abnormal levels of HPL and AFP provided supportive evidence for fetal distress by pointing out those cases in which E3 reading was not a false positive.