Pulmonary Embolism during Pregnancy: Diagnosis with Lung Scintigraphy or CT Angiography?

Published Online:https://doi.org/10.1148/radiol.10100986

We found that lung scintigraphy and CT angiography had comparable performances for the diagnosis of pulmonary embolism in the setting of pregnancy, with no significant differences between the proportions of positive, negative, or indeterminate results; however, the maternal radiation dose was higher with CT angiography.

Purpose

To evaluate the rate of positive, negative, and indeterminate results and the agreement between initial and expert readings for lung scintigraphy and computed tomographic (CT) angiography performed in patients suspected of having pulmonary embolism (PE) during pregnancy.

Materials and Methods

Institutional review board approval was obtained. The authors retrospectively analyzed the images from lung scintigraphy and CT angiography performed in pregnant patients during the past 9 years. Images from 46 CT angiographic examinations performed in 43 patients and 91 of 94 lung scintigraphic examinations were reviewed by experts, whose readings were then compared with the initial reports. For CT angiography, the quality of opacification was graded as good, suboptimal, or poor and intraarterial attenuation was measured.

Results

The rates of positive findings (seven of 43 patients [16%] with CT angiography and 10 of 91 patients [11%] with scintigraphy, P = .36), negative findings (28 of 43 patients [65%] with CT angiography and 64 of 91 patients [70%] with scintigraphy, P = .54), and indeterminate findings (eight of 43 patients [19%] with CT angiography and 17 of 91 patients [19%] with scintigraphy, P = .99) were similar for CT angiography and lung scintigraphy. There were four discrepancies between initial and expert readings for CT angiography (κ = 0.84; confidence interval: 0.68, 0.99) and 14 for lung scintigraphy (κ = 0.75; 95% confidence interval: 0.63, 0.87). Opacification was classified as good for only 23 of the 46 CT angiographic examinations (50%). Attenuation values were significantly different among the groups with good, suboptimal, or poor opacification. Alternative diagnoses unsuspected at chest radiography were demonstrated at CT angiography in five of the 43 patients (12%). The mean maternal radiation dose was 0.9 mSv for lung scintigraphy and 7.3 mSv for CT angiography.

Conclusion

Lung scintigraphy and CT angiography have comparable performances for PE diagnosis during pregnancy. Interobserver agreement is better for CT angiography, which also enables alternative diagnosis of unsuspected disease but delivers higher maternal radiation dose.

© RSNA, 2010

References

  • 1 Heit JA, Kobbervig CE, James AH, Petterson TM, Bailey KR, Melton LJ Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. Ann Intern Med 2005;143(10):697–706. Crossref, MedlineGoogle Scholar
  • 2 Horlander KT, Mannino DM, Leeper KV. Pulmonary embolism mortality in the United States, 1979–1998: an analysis using multiple-cause mortality data. Arch Intern Med 2003;163(14):1711–1717. Crossref, MedlineGoogle Scholar
  • 3 Pahade JK, Litmanovich D, Pedrosa I, Romero J, Bankier AA, Boiselle PM. Quality initiatives: imaging pregnant patients with suspected pulmonary embolism—what the radiologist needs to know. RadioGraphics 2009;29(3):639–654. LinkGoogle Scholar
  • 4 Wells PS, Anderson DR, Rodger M, et al.. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med 2001;135(2):98–107. Crossref, MedlineGoogle Scholar
  • 5 Le Gal G, Righini M, Roy PM, et al.. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med 2006;144(3):165–171. Crossref, MedlineGoogle Scholar
  • 6 Marik PE, Plante LA. Venous thromboembolic disease and pregnancy. N Engl J Med 2008;359(19):2025–2033. Crossref, MedlineGoogle Scholar
  • 7 Le Gal G, Righini M, Sanchez O, et al.. A positive compression ultrasonography of the lower limb veins is highly predictive of pulmonary embolism on computed tomography in suspected patients. Thromb Haemost 2006;95(6):963–966. Crossref, MedlineGoogle Scholar
  • 8 Torbicki A, Perrier A, Konstantinides S, et al.. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J 2008;29(18):2276–2315. Crossref, MedlineGoogle Scholar
  • 9 Larson L, Miller M, Mehta N. Venous thromboembolic disease and pregnancy (letter). N Engl J Med 2009;360(6):638; author reply 639–640. Crossref, MedlineGoogle Scholar
  • 10 Dholakia S, de Mendonca N. Venous thromboembolic disease and pregnancy (letter). N Engl J Med 2009;360(6):639; author reply 639–640. MedlineGoogle Scholar
  • 11 Winer-Muram HT, Boone JM, Brown HL, Jennings SG, Mabie WC, Lombardo GT. Pulmonary embolism in pregnant patients: fetal radiation dose with helical CT. Radiology 2002;224(2):487–492. LinkGoogle Scholar
  • 12 Doshi SK, Negus IS, Oduko JM. Fetal radiation dose from CT pulmonary angiography in late pregnancy: a phantom study. Br J Radiol 2008;81(968):653–658. Crossref, MedlineGoogle Scholar
  • 13 Parker MS, Hui FK, Camacho MA, Chung JK, Broga DW, Sethi NN. Female breast radiation exposure during CT pulmonary angiography. AJR Am J Roentgenol 2005;185(5):1228–1233. Crossref, MedlineGoogle Scholar
  • 14 Bartalena L, Bogazzi F, Braverman LE, Martino E. Effects of amiodarone administration during pregnancy on neonatal thyroid function and subsequent neurodevelopment. J Endocrinol Invest 2001;24(2):116–130. Crossref, MedlineGoogle Scholar
  • 15 U-King-Im JM, Freeman SJ, Boylan T, Cheow HK. Quality of CT pulmonary angiography for suspected pulmonary embolus in pregnancy. Eur Radiol 2008;18(12):2709–2715. Crossref, MedlineGoogle Scholar
  • 16 Andreou AK, Curtin JJ, Wilde S, Clark A. Does pregnancy affect vascular enhancement in patients undergoing CT pulmonary angiography? Eur Radiol 2008;18(12):2716–2722. Crossref, MedlineGoogle Scholar
  • 17 Sostman HD, Coleman RE, DeLong DM, Newman GE, Paine S. Evaluation of revised criteria for ventilation-perfusion scintigraphy in patients with suspected pulmonary embolism. Radiology 1994;193(1):103–107. LinkGoogle Scholar
  • 18 Musset D, Parent F, Meyer G, et al.. Diagnostic strategy for patients with suspected pulmonary embolism: a prospective multicentre outcome study. Lancet 2002;360(9349):1914–1920. Crossref, MedlineGoogle Scholar
  • 19 Huda W, Ogden KM, Khorasani MR. Converting dose-length product to effective dose at CT. Radiology 2008;248(3):995–1003. LinkGoogle Scholar
  • 20 Sostman HD, Stein PD, Gottschalk A, Matta F, Hull R, Goodman L. Acute pulmonary embolism: sensitivity and specificity of ventilation-perfusion scintigraphy in PIOPED II study. Radiology 2008;246(3):941–946. LinkGoogle Scholar
  • 21 Perrier A, Roy PM, Sanchez O, et al.. Multidetector-row computed tomography in suspected pulmonary embolism. N Engl J Med 2005;352(17):1760–1768. Crossref, MedlineGoogle Scholar
  • 22 Cahill AG, Stout MJ, Macones GA, Bhalla S. Diagnosing pulmonary embolism in pregnancy using computed-tomographic angiography or ventilation-perfusion. Obstet Gynecol 2009;114(1):124–129. Crossref, MedlineGoogle Scholar
  • 23 Ridge CA, McDermott S, Freyne BJ, Brennan DJ, Collins CD, Skehan SJ. Pulmonary embolism in pregnancy: comparison of pulmonary CT angiography and lung scintigraphy. AJR Am J Roentgenol 2009;193(5):1223–1227. Crossref, MedlineGoogle Scholar
  • 24 Revel MP, Sanchez O, Dechoux S, et al.. Contribution of indirect computed tomographic venography to the diagnosis of postpartum venous thromboembolism. J Thromb Haemost 2008;6(9):1478–1481. Crossref, MedlineGoogle Scholar
  • 25 Weiss BM, Hess OM. Pulmonary vascular disease and pregnancy: current controversies, management strategies, and perspectives. Eur Heart J 2000;21(2):104–115. Crossref, MedlineGoogle Scholar
  • 26 Kuzo RS, Pooley RA, Crook JE, Heckman MG, Gerber TC. Measurement of caval blood flow with MRI during respiratory maneuvers: implications for vascular contrast opacification on pulmonary CT angiographic studies. AJR Am J Roentgenol 2007;188(3):839–842. Crossref, MedlineGoogle Scholar
  • 27 Scarsbrook AF, Bradley KM, Gleeson FV. Perfusion scintigraphy: diagnostic utility in pregnant women with suspected pulmonary embolic disease. Eur Radiol 2007;17(10):2554–2560. Crossref, MedlineGoogle Scholar
  • 28 Kline JA, Courtney DM, Beam DM, King MC, Steuerwald M. Incidence and predictors of repeated computed tomographic pulmonary angiography in emergency department patients. Ann Emerg Med 2009;54(1):41–48. Crossref, MedlineGoogle Scholar
  • 29 Stein EG, Haramati LB, Bellin E, et al.. Radiation exposure from medical imaging in patients with chronic and recurrent conditions. J Am Coll Radiol 2010;7(5):351–359. Crossref, MedlineGoogle Scholar
  • 30 Litmanovich D, Boiselle PM, Bankier AA, Kataoka ML, Pianykh O, Raptopoulos V. Dose reduction in computed tomographic angiography of pregnant patients with suspected acute pulmonary embolism. J Comput Assist Tomogr 2009;33(6):961–966. Crossref, MedlineGoogle Scholar
  • 31 Yilmaz MH, Albayram S, Yaşar D, et al.. Female breast radiation exposure during thorax multidetector computed tomography and the effectiveness of bismuth breast shield to reduce breast radiation dose. J Comput Assist Tomogr 2007;31(1):138–142. Crossref, MedlineGoogle Scholar
  • 32 Hurwitz LM, Yoshizumi TT, Goodman PC, et al.. Radiation dose savings for adult pulmonary embolus 64-MDCT using bismuth breast shields, lower peak kilovoltage, and automatic tube current modulation. AJR Am J Roentgenol 2009;192(1):244–253. Crossref, MedlineGoogle Scholar
  • 33 Vollmar SV, Kalender WA. Reduction of dose to the female breast in thoracic CT: a comparison of standard-protocol, bismuth-shielded, partial and tube-current-modulated CT examinations. Eur Radiol 2008;18(8):1674–1682. Crossref, MedlineGoogle Scholar
  • 34 Angel E, Wellnitz CV, Goodsitt MM, et al.. Radiation dose to the fetus for pregnant patients undergoing multidetector CT imaging: Monte Carlo simulations estimating fetal dose for a range of gestational age and patient size. Radiology 2008;249(1):220–227. [Published correction appears in Radiology 2010;255(2):664.] LinkGoogle Scholar

Article History

Received May 15, 2010; revision requested June 24; final revision received July 20; accepted July 28; final version accepted August 25.
Published online: Feb 2011
Published in print: Feb 2011