Antenatal Pulmonary Embolism Diagnostics in Pregnant Patients with SARS-CoV-2 Infection in Community Hospitals

Background: The diagnostic evaluation of pulmonary embolism (PE) in pregnancy is challenging as the physiologic changes of pregnancy can mimic several PE symptoms. Acute respiratory infections introduce additional diagnostic complexity by producing systemic inflammation, altering vital signs, and, in some cases, elevating D-dimer levels. As a case in point, we examined how SARS-CoV-2 infection affected presentation, pretest probability, and diagnostic testing in pregnant patients with possible PE. Methods: We performed a retrospective cohort study across 21 community medical centers from 10/1/2021 through 3/30/2023. We included pregnant outpatients ≥18 years evaluated for suspected PE with D-dimer testing, compression ultrasonography, computed tomography pulmonary angiography (CTPA), or lung scintigraphy. We compared patients with and without COVID-19 using bivariate analysis. Results: Among 860 patients, median age was 30.0 years; 39.1% were in the third trimester. COVID-19 was present in 147 (17.1%). Compared with non-COVID-19 patients, those with COVID-19 more often had fever (36.1% vs 4.2%), tachycardia ≥110 bpm (66.0% vs 34.2%), and oxygen saturation <95% (12.2% vs 4.8%), but less often reported chest pain (49.7% vs 65.5%) (all p<0.001). Nearly all patients had low-to-intermediate pretest probability, but intermediate classification was more common with COVID-19 patients (63.3% vs 39.0%; p<0.001). COVID-19 patients more often had elevated D-dimer >1.0 mg/L (49.1% vs 36.4%; p<0.001) and more commonly underwent chest radiography (61.9% vs 50.1%; p=0.004). Among patients who underwent advanced imaging (n=393), CTPA predominated in both cohorts. Overall, PE was rare (n=6; 0.7%), and mortality was low (n=3; 0.3%). Conclusions: COVID-19 in pregnancy was associated with worse vital signs, higher pretest probability, higher D-dimer values, and increased diagnostic testing. These findings illustrate how acute respiratory infections may recalibrate PE risk assessment in pregnancy and highlight the need to refine diagnostic strategies when infection-related physiologic changes are present.