Antenatal Pulmonary Embolism Diagnostics in Patients With COVID-19: A Retrospective Cohort Study

The diagnostic evaluation of pulmonary embolism (PE) in pregnancy is challenging because the physiologic changes of pregnancy can mimic several PE symptoms. Concurrent COVID-19 may further complicate a clinician’s PE diagnostic evaluation by increasing respiratory symptoms and augmenting the prothrombotic state. We examined how COVID-19 affects clinical presentation, PE pretest probability (using the pregnancy-adapted Geneva score), and diagnostic testing for PE in pregnant patients.

We performed a retrospective cohort study across 21 U.S. community medical centers from 10/1/2021 through 3/30/2023. We included pregnant outpatients ≥18 years evaluated for suspected PE with D-dimer testing, compression ultrasonography, computed tomography pulmonary angiography (CTPA), or lung scintigraphy. We excluded patients who had known PE or had early pregnancies that were still unrecognized. The COVID-19 cohort was identified by a positive polymerase chain reaction test in symptomatic patients obtained during the index evaluation or at home or a healthcare setting in the prior 5 days. We compared patients with and without COVID-19 using bivariate analysis.

Among 860 eligible patients, median age was 30.0 years; 39.1% were in the third trimester. COVID-19 was confirmed in 147 (17.1%). Compared with non-COVID-19 patients, those with COVID-19 more often had fever (36.1% vs 4.2%), tachycardia ≥110 bpm (66.0% vs 34.2%), and oxygen saturation <95% (12.2% vs 4.8%), but less often reported chest pain (49.7% vs 65.5%) (all p<0.001). Nearly all patients had low-to-intermediate pretest probability, but intermediate classification was more common in COVID-19 patients (63.3% vs 39.0%; p<0.001). COVID-19 patients more often had elevated D-dimer >1.0 mg/L (49.1% vs 36.4%; p<0.001) and more commonly underwent chest radiography (61.9% vs 50.1%; p=0.004). Among patients who underwent advanced imaging (n=393), CTPA predominated in both cohorts. PE was diagnosed in 6 patients overall: 1 (0.7%) with COVID-19 and 5 (0.7%) without. Mortality was low overall (n=3; 0.3%), occurring in 1 (0.7%) patient with and 2 (0.3%) without COVID-19.

COVID-19 in pregnancy was associated with a higher prevalence of abnormal vital signs, higher pretest probability, higher D-dimer values, and increased diagnostic testing, illustrating how concurrent COVID-19 may affect PE evaluation in pregnancy.