Can cramping in pregnancy be a sign of Pulmonary Embolism (PE)?

Cramping in Pregnancy as a Sign of Pulmonary Embolism (PE)

Cramping alone is not a typical sign of pulmonary embolism (PE) in pregnancy, but PE should be considered when cramping occurs alongside respiratory symptoms such as dyspnea and tachypnea, which are present in >90% of PE cases.

Clinical Presentation of PE in Pregnancy

Pulmonary embolism is a leading cause of pregnancy-related maternal death in developed countries, accounting for approximately 20% of maternal deaths in the United States 1. The clinical presentation of PE in pregnancy is similar to that in non-pregnant patients, with key symptoms including:

• Dyspnea and tachypnea (present in >90% of cases) 1
• Pleuritic chest pain
• Cough
• Sweating
• Tachycardia

The absence of dyspnea and tachypnea makes PE unlikely in most cases 2. However, these symptoms should be interpreted with caution during pregnancy, as they may overlap with normal pregnancy symptoms.

Risk Factors for PE in Pregnancy

Pregnancy itself is a hypercoagulable state due to:

• Hormonal changes affecting coagulation factors
• Mechanical compression of iliac veins by the enlarged uterus
• Decreased venous tone
• Increased coagulation factors II, VII, and X by the third trimester
• Decreased levels of coagulation inhibitor proteins 2

Additional risk factors include:

• History of DVT (odds ratio of 9.4) 1
• Left-sided DVT (more common in pregnancy) 2
• Cesarean section (increases risk 20-fold compared to vaginal delivery) 2

Diagnostic Approach for Suspected PE in Pregnancy

When PE is suspected during pregnancy, even if symptoms have resolved:

1. Apply the modified Wells score (cutoff ≥6 points is most appropriate for pregnancy) 1

2. Assess for DVT symptoms (particularly in the left leg) 2, 1

3. Perform basic diagnostic tests:

   • Chest X-ray
   • Arterial blood gases (drawn in upright position)
   • ECG 2

4. Proceed with appropriate imaging:

   • V/Q scan or CTPA based on clinical findings and chest X-ray results 1
   • Bilateral compression ultrasound of lower extremities may be considered to avoid radiation if DVT symptoms are present 2

Important Considerations

• Never rely solely on clinical symptoms to exclude PE in pregnancy due to overlap with normal pregnancy symptoms 1
• Initiate therapeutic anticoagulation if clinical suspicion remains high while awaiting definitive diagnosis 1
• Low molecular weight heparin is the preferred agent for anticoagulation in pregnancy 1
• Bedside echocardiography should be performed immediately in hemodynamically unstable patients to assess for right ventricular dysfunction 1

Common Pitfalls to Avoid

1. Dismissing respiratory symptoms as normal pregnancy changes - Dyspnea and tachypnea warrant thorough evaluation
2. Delaying imaging due to radiation concerns - The risk of untreated PE far outweighs the minimal radiation risk to the fetus
3. Focusing only on typical PE symptoms - PE can present atypically in pregnancy
4. Failing to consider PE when DVT symptoms are present - DVT can lead to PE and should prompt evaluation

PE remains a significant cause of maternal mortality, with an incidence of approximately 1 in 1000 pregnancies and a mortality rate of about 3% 3. A multidisciplinary approach involving maternal-fetal medicine specialists, cardiologists, and emergency physicians is recommended for complex cases 1.