• David R Vinson, Madeline J Somers, Edward Qiao, Aidan R Campbell, Grace V Heringer, Cole J Florio, Lara Zekar, Cydney E Middleton, Sara T Woldemariam, Nachiketa Gupta, Luke S Poth, Mary E Reed, Nareg H Roubinian, Ali S Raja, and Jeffrey D Sperling.
• The Permanente Medical Group, Pleasanton, California, USA.
• Acad Emerg Med. 2024 Nov 17.

BackgroundNonconsent to pulmonary vascular (or advanced) imaging for suspected pulmonary embolism (PE) in pregnancy can delay diagnosis and treatment, increasing risk of adverse outcomes. We sought to understand factors associated with consent and understand outcomes after nonconsent.MethodsThis retrospective cohort study was undertaken across 21 community hospitals from October 1, 2021, through March 31, 2023. We included gravid patients undergoing diagnostics for suspected PE who were recommended advanced imaging. The primary outcome was verbal consent to advanced imaging. Diagnostic settings were nonobstetric (99% emergency departments [EDs]) and obstetrics (labor and delivery and outpatient clinics). Using quasi-Poisson regression, we calculated adjusted relative risks (aRRs) of consenting with 95% confidence intervals (CIs). We also reported symptom resolution and delayed imaging at follow-up and 90-day PE outcomes.ResultsImaging was recommended for 405 outpatients: median age was 30.5 years; 50% were in the third trimester. Evaluation was more common in nonobstetric (83%) than obstetric settings (17%). Overall, 314 (78%) agreed to imaging and 91 (22%) declined imaging. Consenting was more prevalent in obstetric settings compared with nonobstetric settings: 99% versus 73% (p < 0.001). When adjusted for demographic and clinical variables, including pretest probability, only obstetric setting was independently associated with consenting: aRR 1.26 (95% CI 1.09-1.44). Seventy-nine (87%) patients declining imaging had 30-day follow-up. Eight of 12 who reported persistent or worsening symptoms on follow-up were again recommended advanced imaging and consented. Imaging was negative. None who initially declined imaging were diagnosed with PE or died within 90 days.ConclusionsOne in five gravid patients suspected of PE declined advanced imaging, more commonly in nonobstetric (principally ED) settings than obstetric settings. Patients symptomatic on follow-up responded favorably to subsequent imaging recommendations without 90-day outcomes. Improving the communication and documentation of informed consent and securing close follow-up for nonconsenters may mitigate risks of missed and delayed PE diagnosis.© 2024 Society for Academic Emergency Medicine.

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