A case report highlighting the diagnostic challenge of suspected acute pulmonary embolism in a high-risk pregnant patient whose symptoms worsened despite anticoagulation and a negative V/Q scan.
Negative V/Q and anticoagulation failure in high-risk pregnancy warrant diagnostic caution; hypothesis-generating for refined PE algorithms in this population.
A 34-year-old woman, in her 26th week of gestation, presented with a 2-day history of worsening dyspnoea, nausea, loss of appetite and lower sternal discomfort. She had experienced deep vein thrombosis in her first pregnancy and pulmonary embolism (PE) in her second pregnancy. She was homozygous for the factor V Leiden mutation and on lifelong anti-coagulation. There was no significant family history. She was compliant with her low-molecular-weight heparin therapy during pregnancy, was a non-smoker and drank minimal alcohol. On examination she was afebrile, tachypnoeic at 20 breaths/min with oxygen saturations of 95% on air, blood pressure 132/90 mmHg and tachycardic at 120 beats/min. A soft ejection systolic flow murmur was present at the left sternal edge, with clear vesicular breath sounds. She had mild epigastric tenderness. Twelve-lead ECG confirmed sinus tachycardia. Chest radiography was normal. Acute PE was suspected and therapeutic-dose low-molecular-weight heparin administered. V/Q scintigraphy showed no ventilation–perfusion mismatch. While on the ward, however, she developed worsening dyspnoea and epigastric discomfort.
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parulekar et al. (2011) studied this question.
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