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Evaluation of Dyspnea and Management of Pulmonary Embolism after Surgery

The differential diagnosis for dyspnea after gynecologic surgery includes atelectasis, pneumonia, and pulmonary thromboembolism (PTE).  Clinically significant atelectasis has a low incidence after gynecologic surgery. It usually results from shallow breathing due to postoperative pain and immobility. Incentive spirometry and early ambulation should be encouraged. Pneumonia should be considered in patients with dyspnea and clinical signs of infection including fever, leukocytosis, and purulent sputum.  Evaluation includes a chest radiograph to investigate for an infiltrate.  Management of pneumonia includes antibiotics.

Acute PTE has various presentations depending on the size and location of the thrombus.  Despite perioperative prevention strategies based on risk stratification, thromboembolic events still occur, and dyspnea accompanied by tachycardia, hypoxia, pleuritic chest pain, hemoptysis, and/or cough are the most common symptoms. Hemodynamic instability may also occur.  

Clinical symptoms of PTE are nonspecific.  An assessment tool, such as the modified Wells criteria (Table), may be of benefit.  Other tools incorporating surgery as a risk factor include the Revised Geneva Score, and the Pulmonary Embolism Rule Out Criteria (PERC). In February 2026, the AHA published a comprehensive report to help providers risk stratify patients and guide clinical management of patients you suspect could have a PTE. Utilizing the Wells Criteria, a score greater than 4.0 (high probability) is considered a positive result (PTE likely).  The Wells Criteria reflects the importance of maintaining a high index of suspicion by assigning 3 points to the absence of another explanation for the dyspnea.   If the patient is stable and PTE is considered likely, CT pulmonary angiography should be performed.  While CT pulmonary angiography is sensitive and specific for identifying PTE (83% and 96%, respectively), initial alternate testing utilizing D-dimer along with the YEARS criteria may be indicated in patients in whom there is an intermediate clinical probability.

 

Modified Wells Criteria		Score
Clinical symptoms of DVT (Leg swelling/Pain with palpation in deep vein region)		3
Other dx less likely		3
Heart Rate > 100		1.5
Immobilization/Surgery		1.5
Prior DVT/PTE		1.5
Hemoptysis		1
Malignancy		1
PTE Likely >4.0
PTE Unlikely ≤=4.0

 

Management of a patient with a suspected PTE involves supportive care and anticoagulation.   A multidisciplinary approach should be employed as appropriate based on available hospital resources. Initial management requires determination of outpatient or inpatient management through risk assessment. Inpatient management can include intravenous fluids in small amounts (500 mL) to support preload, inhaled pulmonary vasodilators for reduction of right ventricular afterload and vasopressor support for patients in cardiogenic shock.. Hypoxemia requires oxygen supplementation and may require intubation.  In severe cases, thrombolytic therapy may be considered.  However, the mainstay of PTE treatment is anticoagulation.  Immediate anticoagulation should be initiated during evaluation when there is a high clinical suspicion (>4) and where diagnostic assessment will be delayed more than four hours. 

Options for initial anticoagulation include direct oral anticoagulation (DOAC), subcutaneous low molecular weight heparin (LMWH), intravenous unfractionated heparin (UFH), and subcutaneous UFH.  The choice of therapy depends on factors such as the risk of postoperative bleeding, renal function and acuity.  If parenteral anticoagulation is required, the oral anticoagulants (warfarin or DOAC) have medication specific transition protocols that should be referenced. Depending on the agent used, monitoring for therapeutic efficacy may be needed.  There is no single recommendation for the length of time oral anticoagulation should be continued.  It is often stopped after 3-6 months, but should be continued for a longer period of time if other predisposing conditions exist.

Further Reading:

American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology. Prevention of Venous Thromboembolism in Gynecologic Surgery: ACOG Practice Bulletin, Number 232. Obstet Gynecol. 2021 Jul 1 (reaffirmed 2025);138(1):e1-e15. doi: 10.1097/AOG.0000000000004445. PMID: 34259490.

Creager MA, Barnes GD, Giri J, Mukherjee D, Jones WS, et al. 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2026 Mar 24;153(12):e977-e1051. doi: 10.1161/CIR.0000000000001415. Epub 2026 Feb 19. PMID: 41712677.

Renner, E, Barnes, G. Antithrombotic Management of Venous Thromboembolism: JACC Focus Seminar. JACC. 2020 Nov, 76 (18) 2142–2154. https://www.jacc.org/doi/10.1016/j.jacc.2020.07.070

Initial approval January 2015; Revised January 2018; Minor Revision July 2019; Revised March 2021; Reaffirmed & Reference update September 2022; Reaffirmed July 2024. Minor Revision March 2026.

 

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