ABC | Volume 114, Nº5, May 2020

Statement Brazilian Cardiology Society Statement for Management of Pregnancy and Family Planning in Women with Heart Disease – 2020 Arq Bras Cardiol. 2020; 114(5):849-942 Table 34 – Examinations used for diagnosing deep vein thrombosis Examinations Accuracy Advantages Disadvantages Physical Examination Se - 25% to 35% Sp - 30% to 50% Harmless, may suggest other diagnoses None D-dimer dosage Se - 100% Sp - 60% Excellent negative predictive value** Must be associated with ultrasound Compression ultrasound/duplex scan Se - 96% for proximal veins Sp - 98% Low cost Easily repeated None MR angiography Se - 91.5%* Sp - 94.8%* Pelvic and iliac vein thrombosis Cost Venous CT angiography Se - 95.5%* Sp - 95.2%* It may be performed in conjunction with pulmonary CT angiography Cost Use of contrast Radiation CT: computed tomography; MR: magnetic resonance; Se: sensitivity; Sp: specificity. * Data from meta-analysis of largely heterogeneous studies. ** Not validated for gestation. The choice between V/Q and CTPA is divergent. Most recommendations indicate V/Q scintigraphy as a first choice, especially perfusion, in the presence of normal chest X-ray. Others, however, recommend using CTPA with low doses for diagnosing PTE, even though they produce a higher proportion of inconclusive results during gestation. Approximately 80% of scintigraphy examinations are diagnostic, i.e., 70% are normal, and 5% to 10% are high probability. Table 35 shows absorbed radiation doses of diagnostic tests for PTE during pregnancy. 131,340 Pregnancy-Adapted YEARS Algorithm 334 was applied for the diagnosis of PTE in a population of pregnant women and showed that in the absence of factors such as deep venous thrombosis, hemoptysis, PTE as the most likely diagnosis and, D-dimer not exceeding 1000 ng/ml, the diagnosis of PTE it can be ruled out and, consequently, chest angiotomography could be avoided in 32 to 65% of patients. 334 5.2.4.6. Differential Diagnosis Differential diagnosis of PTE is wide-ranging, given that pulmonary embolism has clinical manifestations similar to those of pneumonia, HF, and AMI. For this reason, it is wise to exclude the presence of coexisting pulmonary embolism with pneumonia manifestations. From the peripheral point of view, Figure 9 – Flowchart used for investigating deep vein thrombosis during gestation. DVT: deep vein thrombosis; MR: magnetic resonance; MRA: magnetic resonance angiography; US: ultrasound. Clinical suspicion of DVT Suspicion of DVT (clinical/LEFT rule) Full leg ultrasound, including iliac veins Compression US Treatment D-dimer dosage Suspicion of iliac DVT Negative Negative Negative Inconclusive No Positive Positive Positive Diagnostic follow up If clinical suspicion is high or LEFT rule Serial US 2-7 days / MR Clinical follow up Initiate treatment Yes Clinical follow up Repeat US in 3-7 days MRA or iliac US Table 35 – Estimated absorbed radiation of procedures used to diagnose pulmonary thromboembolism Test Estimated fetal radiation (mSv) Estimated maternal breast radiation (mSv) Chest X-ray < 0.01 0.01 Pulmonary perfusion scintigraphy with technetium 99m: Low dose (40 MBq) 0.11 to 0.20 0.28 to 0.50 High dose (200 MBq) 0.20 to 0.60 1.20 Pulmonary ventilation scintigraphy 0.10 to 0.30 < 0.01 Pulmonary angiotomography 0.24 to 0.66 10 to 70 mSv: millisievert. 908