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Dual-Patient Interactive Case Discussion

Select a patient below to open their clinical trajectory and bedside vitals.

BEDSIDE TELEMETRY MONITOR ACTIVE

HR (bpm)

114

BP (mmHg)

108/68

SpO2 (RA)

93%

Shock Index

1.05

Adaptive

ESC / PERT Guideline Pearl

Pregnant vs. Non-Pregnant PE Management Matrix

Clinical Domain	Pregnant Patient	Non-Pregnant Patient
1. Pretest Scoring	Pregnancy-adapted YEARS. Wells score not validated due to altered baseline HR and dyspnea.	Wells Score (dichotomized ≤4 vs >4) or Revised Geneva Score.
2. D-Dimer Cutoffs	YEARS thresholds: 1,000 ng/mL if 0 items; 500 ng/mL if ≥1 item.	Age-adjusted cutoff: Age × 10 µg/L FEU (for age >50).
3. First-Line Imaging	Leg Compression Ultrasound (CUS) first to spare fetal/breast radiation if DVT is found.	Proceed straight to CTPA if pretest probability is high.
4. Thoracic Imaging	Normal CXR → V/Q scan preferred (<0.8 mGy to breast). Abnormal CXR → Low-dose CTPA.	CTPA is the standard gold standard.
5. Anticoagulant Choice	Therapeutic LMWH. DOACs & Warfarin strictly contraindicated.	DOACs (Apixaban/Rivaroxaban) are Class I-A recommendation.
6. Delivery Timing	Hold therapeutic LMWH 24 hours prior to elective induction/epidural.	Not applicable.

Pregnancy-Adapted YEARS

Obstetric

1. Clinical signs of DVT

2. Hemoptysis

3. PE most likely diagnosis

D-Dimer Level (ng/mL):

Wells Score & Dimer

General

Patient Age:

D-Dimer (ng/mL):

DVT Signs (+3) PE #1 dx (+3) HR > 100 (+1.5) Immobilized (+1.5) Prev VTE (+1.5) Hemoptysis (+1.0) Cancer (+1.0)

Simplified PESI

Prognostic

Age > 80 years History of Cancer Cardiopulmonary Dz HR ≥ 110 bpm Systolic BP < 100 SaO2 < 90%

Radiation Dosimetry & Patient Counseling Laboratory

Key Dosimetry Rules:

Fetal Dose is Extremely Safe: Both CTPA and V/Q deliver doses drastically below the 50 mGy teratogenic threshold.
Maternal Breast Radiosensitivity: CTPA delivers 10–20 mGy to the breasts. V/Q scintigraphy delivers <0.8 mGy (>20 times lower).

Interactive Gestational Age Selector:

28 Wks

Latest Guidelines & Landmark Trials

1. Catheter-Directed Thrombectomy (FLASH & HI-PEITHO)

Mechanical thrombectomy achieves immediate reduction in RV/LV ratio with minimal bleed rates. Excellent alternative in pregnancy if lytics are too high risk.

2. Pregnancy-Adapted YEARS Algorithm (ARTEMIS)

Safely rules out PE without CTPA in up to 39% of pregnant women across all trimesters. Never use standard D-dimer cutoffs alone in pregnancy.

3. PERT Teams

Hospital-wide Pulmonary Embolism Response Teams accelerate time-to-treatment and lower mortality in submassive/massive PE.

4. CTEPH Screening

Persistent exercise limitation occurs in 20-50%. Routine follow-up at 3 to 6 months with echo and V/Q scan is mandatory to rule out CTEPH.

Clinical Board Review Quiz

Score: 0 / 4

Q1 • Anticoagulation SafetyUnanswered

Pregnant 26 wks with PE. Which regimen is appropriate?

Q2 • Imaging StrategyUnanswered

28-week pregnant with normal baseline CXR. Why favor V/Q scan over CTPA?

Q3 • Neuraxial TimingUnanswered

Pregnant patient on therapeutic LMWH (Enoxaparin 1 mg/kg BID). How many hours to hold prior to epidural?

Q4 • Triage & ManagementUnanswered

54yo non-pregnant male. Normotensive. RV/LV ratio 1.3, positive Troponin. Management?

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