Is attributing a pregnant patient's symptoms suggestive of pulmonary embolism (PE) to pregnancy-related symptoms without proper diagnostic workup considered malpractice?

Failure to Properly Evaluate Pulmonary Embolism Symptoms in Pregnancy May Constitute Malpractice

Attributing symptoms suggestive of pulmonary embolism (PE) to pregnancy without proper diagnostic workup is considered medical malpractice, as PE is a leading cause of pregnancy-related mortality and requires prompt investigation regardless of pregnancy status. 1, 2

Understanding the Risk of PE in Pregnancy

Pulmonary embolism is a significant cause of maternal mortality, accounting for approximately 20% of maternal deaths in the United States 1. The overlap between normal pregnancy symptoms and PE symptoms creates a diagnostic challenge, but this challenge does not excuse failure to investigate when PE is suspected.

Key points:

• Pregnancy increases the risk of venous thromboembolism (VTE)
• PE symptoms can mimic normal pregnancy symptoms
• Less than 10% of pregnant women with concerning clinical features are ultimately diagnosed with VTE 1

Standard of Care for Suspected PE in Pregnancy

The American Thoracic Society/Society of Thoracic Radiology clinical practice guidelines clearly establish that:

1. Clinical symptoms should never be relied upon to exclude PE in pregnancy 1
2. A structured diagnostic algorithm must be followed when PE is suspected 1, 2
3. Proper imaging studies must be performed despite concerns about radiation 1

Diagnostic Algorithm That Should Be Followed

When PE is suspected in a pregnant patient, the following steps should be taken:

1. Apply modified Wells score to assess clinical probability 2
2. Assess for DVT symptoms - if present, perform bilateral compression ultrasound 1, 2
3. Perform chest X-ray as the first radiation-associated procedure 1
4. Follow with appropriate imaging based on CXR results:
   • If CXR normal: Proceed with lung scintigraphy (V/Q scan) 1
   • If CXR abnormal: Proceed with CTPA 1
   • If V/Q scan non-diagnostic: Proceed with CTPA 1, 2

Why Dismissing PE Symptoms as "Pregnancy-Related" Is Malpractice

1. Failure to follow established guidelines: The American Thoracic Society explicitly states that clinical symptoms alone cannot rule out PE in pregnancy 1

2. Ignoring a leading cause of maternal mortality: PE accounts for 20% of maternal deaths, making it negligent to dismiss symptoms without proper investigation 1

3. Disregarding radiation safety evidence: Guidelines clearly state that "fetal radiation doses delivered in utero by properly performed diagnostic tests such as those used for suspected PE in the mother present no measurably increased risk" 1

4. Misunderstanding prevalence: While PE is confirmed in only 3-6% of pregnant women with suspected symptoms, this low prevalence does not justify failure to investigate 1

Common Pitfalls in PE Diagnosis During Pregnancy

1. Overreliance on D-dimer testing: D-dimer cannot be used to exclude PE in pregnancy due to documented false negatives 1

2. Fear of radiation exposure: The risk of radiation from diagnostic imaging is considered "negligible at 50 mGy or less when compared with other risks of pregnancy" 1

3. Failure to recognize urgency: Delays in diagnosis and treatment of PE significantly increase mortality risk 2

4. Attributing symptoms to normal pregnancy: Symptoms like dyspnea, tachycardia, and chest pain can occur in both normal pregnancy and PE, but this overlap requires more investigation, not less 1, 3

Legal Implications

From a medical-legal perspective, failure to investigate symptoms suggestive of PE in a pregnant patient constitutes a deviation from the standard of care. If this failure results in harm or death, it meets the criteria for medical malpractice:

1. A duty of care existed (physician-patient relationship)
2. The standard of care was breached (failure to investigate PE symptoms)
3. The breach caused harm (delayed diagnosis led to complications or death)
4. Damages resulted from the harm

Conclusion

The evidence clearly establishes that dismissing symptoms suggestive of PE as merely "pregnancy-related" without appropriate diagnostic workup represents a significant deviation from the standard of care and constitutes medical malpractice. Guidelines from multiple professional organizations emphasize the importance of thorough investigation of suspected PE in pregnancy, regardless of the overlap with normal pregnancy symptoms.