Pregnancy-Adapted Geneva Score – Pre-test Probability of Acute PE in Pregnancy

November 12, 2021

Written by Bo Stubblefield

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In this prospective cohort, a pregnancy-adapted Geneva Score demonstrated better diagnostic accuracy than the original Geneva Score in identifying pregnant patients as low, intermediate, and high risk for acute pulmonary embolism (PE).

Why does this matter?
Available clinical decision tools (CDTs) for PE have not been derived or validated on a large-scale basis in pregnant patients (1). Two CDTs: the Geneva Score (CT-PE pregnancy study) and pregnancy-adapted YEARS algorithm (ARTEMIS study) and have been used in combination with D-dimer as diagnostic strategies to assess pre-test probability of acute PE in pregnancy (2-4). Although, more limited studies (5,6) have suggested clinical equipoise in their use (7), these CDTs should be considered in pregnant patients with suspected PE.

PE in pregnancy: better tools on the horizon?
This work derived a pregnancy-specific Geneva Score from the CT-PE pregnancy cohort (2) and compared the diagnostic accuracy of this derived score to the Geneva Score used in the original cohort. Data from the multicenter, prospective management outcome study group included 395 women with suspected PE. Geneva Score criteria for age and heart rate were modified in the pregnancy-adapted score and clinical weighting for active malignancy was removed (see table). Scores can range from 0-20; low is 0-1, intermediate 2-6, and high ≥7. The area under the curve (AUC) for the receiver operating characteristic (ROC) was 0.795 (95%CI 0.690-0.899) for the pregnancy-adapted compared to 0.684 (95%CI 0.563-0.805). Although the pregnancy-adapted Geneva Score shows promising discriminative power, it will need to be tested in a prospective study before it is ready for prime time.

From cited article

Another Spoonful

1. Refresher on ROC analyses

2. EM Ottawa blog discusses diagnostic dilemmas for PE in pregnancy

3. Rebel EM blog discusses DiPEP Study

Source
Assessing the clinical probability of pulmonary embolism during pregnancy: The Pregnancy-Adapted Geneva (PAG) score. J Thromb Haemost. 2021 Sep 8. doi: 10.1111/jth.15521.

Reviewed by Clay Smith

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Works Cited

1. Chan WS. Can pregnancy-adapted algorithms avoid diagnostic imaging for pulmonary embolism? Hematology Am Soc Hematol Educ Program 2020;2020:184-9.

2. Righini M, Robert-Ebadi H, Elias A, et al. Diagnosis of Pulmonary Embolism During Pregnancy: A Multicenter Prospective Management Outcome Study. Ann Intern Med 2018;169:766-73.

3. van der Pol LM, Tromeur C, Bistervels IM, et al. Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. The New England journal of medicine 2019;380:1139-49.

4. Bellesini M, Robert-Ebadi H, Combescure C, Dedionigi C, Le Gal G, Righini M. D-dimer to rule out venous thromboembolism during pregnancy: A systematic review and meta-analysis. Journal of thrombosis and haemostasis : JTH 2021;19:2454-67.

5. Goodacre S, Horspool K, Nelson-Piercy C, et al. 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. BJOG 2019;126:383-92.

6. Goodacre S, Nelson-Piercy C, Hunt BJ, Fuller G. Accuracy of PE rule-out strategies in pregnancy: secondary analysis of the DiPEP study prospective cohort. Emerg Med J 2020;37:423-8.

7. Goodacre S, Hunt BJ, Nelson-Piercy C. Diagnosis of Suspected Pulmonary Embolism in Pregnancy. The New England journal of medicine 2019;380:e49.