Would sending a pregnant patient home without evaluating for pulmonary embolism (PE) be considered malpractice?

Sending a Pregnant Patient Home Without Evaluating for Pulmonary Embolism is Malpractice

Sending a pregnant patient home without evaluating for pulmonary embolism (PE) would constitute malpractice, as PE is a leading direct cause of maternal mortality and requires prompt evaluation. 1, 2

Why This Would Be Considered Malpractice

1. High mortality risk: PE is one of the leading causes of pregnancy-related deaths in developed countries, accounting for 20% of maternal deaths in the United States 2

2. Increased risk during pregnancy: Pregnancy increases the risk of venous thromboembolism (VTE) fourfold to sixfold 1

3. Guidelines mandate evaluation: Multiple clinical practice guidelines explicitly state that pregnant women with suspected PE require thorough evaluation:

   • The American Thoracic Society/Society of Thoracic Radiology guidelines recommend a structured diagnostic approach for all pregnant women with suspected PE 1
   • The British Thoracic Society guidelines state that "all pregnant and postpartum women presenting with suspected PE or confirmed PE should be reviewed by a consultant and discussed with maternity services prior to discharge" 1

Proper Diagnostic Approach

When a pregnant woman presents with symptoms suggestive of PE, the following diagnostic algorithm should be implemented:

1. Initial Assessment:

   • Modified Wells score is considered the most appropriate scoring system for evaluating suspected PE in pregnancy 2
   • The pregnancy-adapted YEARS algorithm combined with D-dimer levels can safely exclude PE in some pregnant patients 2, 3

2. Imaging Pathway:

   • Chest radiography (CXR) should be performed as the first radiation-associated procedure 1, 2
   • If CXR is normal, lung scintigraphy (V/Q scan) is recommended as the next imaging test 1, 2
   • If CXR is abnormal, CTPA is suggested as the next imaging test 1, 2
   • If V/Q scan is nondiagnostic, further testing with CTPA is recommended 1

3. Treatment During Evaluation:

   • Anticoagulation should be initiated while awaiting diagnostic confirmation unless contraindicated 2
   • Low molecular weight heparin (LMWH) is the preferred agent in pregnancy 2

Common Pitfalls to Avoid

1. Dismissing symptoms as normal pregnancy changes: Many symptoms of PE overlap with physiological changes of pregnancy, leading to delayed recognition 4, 3

2. Excessive concern about radiation: While radiation exposure is a concern, the risk to the mother from untreated PE far outweighs the theoretical risk to the fetus from diagnostic imaging 1, 2

3. Failure to initiate treatment during evaluation: Anticoagulation should be started while awaiting diagnostic confirmation unless contraindicated 2

4. Lack of multidisciplinary consultation: Guidelines recommend discussion with maternity services and appropriate specialists before discharge 1, 2

Clinical Implications

The failure to evaluate a pregnant patient with suspected PE before sending them home represents a significant deviation from the standard of care. Given that PE is a leading cause of maternal mortality with a mortality rate of approximately 3% in pregnant women 5, discharging such a patient without proper evaluation exposes them to unnecessary and potentially fatal risk.

The diagnostic approach for PE in pregnancy is well-established in multiple guidelines, and failure to follow these guidelines when a pregnant patient presents with symptoms suggestive of PE would likely be viewed as negligent from a medical-legal perspective.