PE in Pregnancy – YEARS Algorithm

Written by Sam Parnell

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The Pregnancy-Adapted YEARS Algorithm safely and accurately ruled out pulmonary embolism (PE) for pregnant patients and reduced the rate of CT pulmonary angiography (CTPA) across all trimesters.

Why does this matter?
PE is one of the leading causes of maternal death during pregnancy. However, making the diagnosis can be challenging. The d-dimer test has decreased specificity and accuracy during pregnancy, and imaging modalities such as CTPA and ventilation-perfusion (VQ) scanning expose both the fetus and mother to radiation. But what if there was a clinical decision rule that could safely rule out PE in pregnant patients and reduce the rate of CTPA or VQ imaging?

Pregnant with Anticipation: We have been waiting YEARS for this algorithm
This was a prospective international study of 498 pregnant women with suspected PE. The pregnancy-adapted YEARS algorithm (Figure below) was used to guide diagnostic testing and management.

Using this protocol, PE was diagnosed in 4% of patients. CTPA was avoided in 39% of all patients. Only one patient not initially diagnosed with venous thromboembolism was diagnosed with DVT during the 3-month follow-up, and no patients were diagnosed with subsequent PE during follow-up.  The efficiency of the algorithm was highest during the first trimester (when radiation is potentially most detrimental to the developing fetus) and lowest during the third trimester. In total, CTPA was avoided in 65% of patients in the first trimester, 46% in the second trimester, and 32% in the third trimester.  This seems to be a viable clinical decision tool to rule out PE in pregnant patients and safely reduce CTPA use.

Source
Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism.  N Engl J Med. 2019 Mar 21;380(12):1139-1149. doi: 10.1056/NEJMoa1813865.

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Reviewed by Clay Smith