How should haemoptysis be evaluated and managed in a pregnant woman?

Evaluation of Haemoptysis in Pregnancy

Initial Priority: Rule Out Pulmonary Embolism

Haemoptysis in pregnancy must be presumed to be pulmonary embolism (PE) until proven otherwise, as pregnancy-associated venous thromboembolism is a leading cause of maternal mortality and PE is the most common life-threatening cause of haemoptysis in this population. 1, 2

Immediate Assessment and Stabilization

Maternal Stabilization Takes Priority

• Maternal assessment and stabilization always precedes fetal evaluation - the mother must be stabilized first to optimize outcomes for both patients 3
• Administer supplemental oxygen immediately to maintain maternal oxygen saturation >95% to ensure adequate fetal oxygenation 3
• Establish two large-bore (14-16 gauge) intravenous lines for potential resuscitation 3
• Position the patient in left lateral decubitus after mid-pregnancy to prevent aortocaval compression and optimize venous return 3

Critical Clinical Assessment

• Assess for hemodynamic instability (hypotension, tachycardia, altered mental status) which would indicate massive PE requiring ICU admission 4
• Evaluate for signs of right ventricular dysfunction or life-threatening hemodynamic compromise 1
• Document volume of haemoptysis and associated symptoms (chest pain, dyspnea, syncope) 5
• Examine for signs of deep vein thrombosis in lower extremities 2

Diagnostic Workup

Imaging Studies - Do Not Delay

Radiographic studies indicated for maternal evaluation, including chest CT pulmonary angiography, should not be deferred or delayed due to concerns regarding fetal radiation exposure. 3

• Computed tomographic pulmonary angiography (CTPA) is the preferred initial imaging modality for suspected PE in pregnancy, as maternal benefit outweighs minimal fetal radiation risk 3, 2
• Ventilation-perfusion (V/Q) scanning is an acceptable alternative if CTPA is unavailable 2
• Compression ultrasound of lower extremities should be performed to detect deep vein thrombosis 2
• Chest radiograph can help identify alternative diagnoses (pneumonia, malignancy, tuberculosis) 5

Laboratory Evaluation

• Complete blood count to assess for anemia from blood loss 3
• Coagulation panel including fibrinogen level (normal pregnancy fibrinogen should be elevated; levels <200 mg/dL suggest consumptive coagulopathy) 3
• D-dimer has limited utility in pregnancy as it is physiologically elevated 2
• Arterial blood gas if respiratory compromise is present 2

Management Based on Diagnosis

If Pulmonary Embolism is Confirmed

Initiate therapeutic-dose low-molecular-weight heparin (LMWH) immediately - specifically enoxaparin 1 mg/kg subcutaneously twice daily or 1.5 mg/kg once daily. 1, 4

• LMWH is strongly preferred over unfractionated heparin due to more predictable therapeutic levels, superior efficacy, lower risk of heparin-induced thrombocytopenia, and reduced osteoporosis risk 1, 4
• Routine anti-factor Xa monitoring is not required unless there are concerns about extreme body weight, renal impairment, or uncertain therapeutic effect 1, 4
• Continue therapeutic anticoagulation throughout pregnancy and for at least 6 weeks postpartum, with minimum total duration of 3 months from diagnosis 4

Thrombolytic Therapy Considerations

For pregnant women with acute PE and life-threatening hemodynamic instability (sustained hypotension, shock), systemic thrombolytic therapy should be administered in addition to anticoagulation. 1

• For pregnant women with acute PE and right ventricular dysfunction WITHOUT hemodynamic instability, thrombolytic therapy should NOT be given - the bleeding risk outweighs potential benefit 1
• Thrombolytic agents (alteplase, streptokinase) do not cross the placenta, but maternal bleeding complications occur in approximately 8% of cases, primarily from the genital tract 6
• Major bleeding risk is substantial (63 more per 1000 patients), with increased intracranial hemorrhage risk (7 more per 1000) 1

If PE is Excluded - Alternative Diagnoses

When PE is ruled out but haemoptysis persists, consider:

• Malignancy (including well-differentiated fetal adenocarcinoma) - requires chest CT and bronchoscopy if clinically indicated 5
• Idiopathic pregnancy-related haemoptysis with bronchial hypervascularization - managed with blood pressure control and bronchial artery embolization if massive 7
• Pulmonary hypertension (particularly in patients with known cardiac disease or Eisenmenger syndrome) - associated with significant haemoptysis risk and requires anticoagulation consideration on individual basis 1
• Infection (tuberculosis, pneumonia) - standard diagnostic workup and treatment 5

Fetal Monitoring (If ≥23 Weeks Gestation)

• Initiate continuous electronic fetal monitoring for at least 4 hours for all viable pregnancies 3
• Extend monitoring to 24 hours if adverse factors present (uterine tenderness, vaginal bleeding, abnormal fetal heart rate pattern) 3
• Perform obstetrical ultrasound prior to discharge to assess fetal well-being 3

Critical Pitfalls to Avoid

• Never delay therapeutic anticoagulation while awaiting imaging or specialist consultation - treatment delays increase maternal mortality and morbidity 4
• Never use prophylactic-dose anticoagulation for acute PE - therapeutic dosing is mandatory 4
• Never withhold indicated radiographic studies due to fetal radiation concerns - maternal benefit takes priority 3
• Do not assume normal fetal heart tracing excludes serious maternal pathology - maternal stabilization remains the priority 3
• Do not use vitamin K antagonists (warfarin) or direct oral anticoagulants during pregnancy - these are contraindicated due to teratogenicity and placental transfer 4
• Avoid vasopressors unless hypotension is intractable and unresponsive to fluid resuscitation, as they adversely affect uteroplacental perfusion 3

Rhesus Status Management

• Administer anti-D immunoglobulin to all Rh-negative pregnant trauma or bleeding patients 3
• Perform Kleihauer-Betke test to quantify maternal-fetal hemorrhage and determine need for additional anti-D immunoglobulin doses 3