Is it considered malpractice if a doctor dismisses pulmonary embolism (PE) symptoms in a pregnant patient due to overlap with pregnancy symptoms?

Dismissing PE Symptoms in Pregnancy Could Constitute Malpractice

Dismissing pulmonary embolism (PE) symptoms in a pregnant patient solely because they overlap with pregnancy symptoms is considered negligent medical practice and could constitute malpractice, as PE remains one of the leading causes of maternal death in high-income countries. 1, 2

Understanding the Diagnostic Challenge

Diagnosing PE during pregnancy is particularly challenging for several reasons:

• Signs and symptoms of PE significantly overlap with normal physiological changes of pregnancy 2
• The prevalence of confirmed PE is low (2-7%) among pregnant women investigated for the disease 1
• VTE is ultimately confirmed in less than 10% of pregnant women who present with concerning clinical features 2

However, these challenges do not justify dismissing symptoms, as the consequences can be fatal.

Standard of Care for Suspected PE in Pregnancy

When PE is suspected in a pregnant patient, the standard of care requires:

1. Immediate risk assessment:

   • Use of modified Wells score (cutoff ≥6 points) or pregnancy-adapted YEARS algorithm 2
   • Assessment of clinical probability combined with D-dimer measurement 1

2. Appropriate diagnostic workup:

   • Initiation of anticoagulation therapy while diagnostic workup is ongoing (unless contraindicated) 2
   • Imaging studies based on clinical presentation:
     • If chest X-ray normal: CTPA or perfusion lung scan
     • If chest X-ray abnormal: CTPA 1
   • Bilateral compression ultrasound of lower extremities if DVT symptoms are present 2

3. Multidisciplinary approach:

   • Involvement of specialists in maternal-fetal medicine, cardiology, hematology, and emergency medicine 2

Why Dismissal Could Constitute Malpractice

Dismissing PE symptoms in pregnancy could constitute malpractice for several reasons:

1. Failure to meet standard of care: The European Society of Cardiology and American College of Obstetricians and Gynecologists guidelines clearly establish protocols for evaluating suspected PE in pregnancy 1, 2

2. Ignoring established risk factors: Pregnancy itself increases VTE risk, which peaks during the post-partum period 1

3. Delayed diagnosis impacts mortality: Maternal mortality from PE has been attributed to delayed recognition and investigations 3

4. Available diagnostic algorithms: Validated diagnostic approaches exist that can safely exclude PE in pregnancy, such as the pregnancy-adapted YEARS algorithm combined with D-dimer levels 1

Red Flags That Should Never Be Dismissed

Even when symptoms overlap with normal pregnancy, the following should trigger immediate PE evaluation:

• Pleuritic chest pain
• Sudden onset dyspnea disproportionate to pregnancy stage
• Hemoptysis
• Syncope or presyncope
• Signs of DVT (unilateral leg swelling, pain)
• Tachycardia or hypoxemia disproportionate to pregnancy stage

Pitfalls to Avoid

1. Overreliance on D-dimer: D-dimer levels continuously increase during pregnancy, with levels above the VTE 'rule-out' threshold in almost one-quarter of pregnant women in the third trimester 1

2. Radiation concerns: Modern imaging techniques expose both mother and fetus to radiation doses well below harmful thresholds 1, 2

3. Assuming symptoms are "just pregnancy": This cognitive bias can lead to dangerous delays in diagnosis and treatment

4. Failing to involve specialists: Complex cases benefit from multidisciplinary input 2

In summary, while diagnosing PE in pregnancy presents unique challenges, dismissing symptoms due to overlap with pregnancy is not acceptable medical practice and could constitute malpractice given the potentially fatal consequences and established diagnostic protocols.