Venous Thromboembolism Prophylaxis Should Be Recommended for Antepartum Admissions and Cesarean Delivery if Age and Body Mass Index Are Greater Than 35

Abstract

Objective Venous thromboembolism (VTE) is a major cause of maternal morbidity and mortality. Current expanded treatment recommendations result in the inclusion of a large percentage of the obstetric population, which has limited their adoption. The purpose of this study was to identify a population at high risk for VTE, with minimal impact on the number of patients that would qualify for expanded treatment.

Study Design We performed a retrospective analysis of a large obstetric population. International Classification of Diseases, 10th Revsion (ICD-10) codes for VTE were used to identify patients presenting for obstetric or postpartum (PP) care from January 2016 to March 2018. The review focused on high-risk factors (history of VTE or high-risk thrombophilia), antepartum hospital admissions that were >72 hours in the previous 30 days, use of sequential compression devices, body mass index (BMI; kg/m²), age, and mode of delivery. Pharmacologic treatment efficacy was set at 90, 75, or 50%.

Results During the 27-month review period, there were 120,235 deliveries and 93 had a VTE event in the index pregnancy or within 4 weeks PP (7.7/10,000 births). A history of VTE or high-risk thrombophilia was seen in 25.8% of cases. Antepartum admission was noted in 40.9%, and the combination of cesarean delivery (CD) with age and BMI ≥35 (Age + BMI + CD) was noted in 17.3% of PP cases. Targeting these latter two groups for VTE prophylaxis with a 75% efficacy suggests that 34% of the VTE events would likely have been prevented while increasing the total population treated by approximately 2%.

Conclusion Expanding pharmacologic prophylactical coverage to include an antepartum admission of >72 hours and those with Age + BMI + CD would result in about a one-third reduction in total VTE events with about 2% requiring treatment. These data support some of the suggested recommendations for expanded pharmacological deep venous thrombosis prophylaxis.

Key Points

• CD, and BMI and age >35 are high-risk factors for VTE.

• Antepartum admission >72 hours is a high-risk factor for VTE.

• Targeting antepartum admissions, CD, and BMI and age >35 would reduce VTE events by about 33%.

Keywords

venous thromboembolism - antepartum admission - prevention - maternal morbidity

• References

• 1 Royal College of Obstetricians and Gynecologists. Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium. 2015 . Accessed January 8, 2024 at: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg37a.pdf
• 2 American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin No. 196: Thromboembolism in pregnancy. Obstet Gynecol 2018; 132 (01) e1-e17
• 3 Varrias D, Spanos M, Kokkinidis DG, Zoumpourlis P, Kalaitzopoulos DR. Venous thromboembolism in pregnancy: challenges and solutions. Vasc Health Risk Manag 2023; 19: 469-484
• 4 Friedman AM. Obstetric venous thromboembolism prophylaxis, risk factors and outcomes. Curr Opin Obstet Gynecol 2021; 33 (05) 384-390
• 5 California Department of Public Health. Pregnancy-Related Mortality. 2023 . Accessed January 8, 2024 at: https://www.cdph.ca.gov/Programs/CFH/DMCAH/surveillance/Pages/Pregnancy-Related-Mortality.aspx
• 6 Friedman AM, Ananth CV, Lu YS, D'Alton ME, Wright JD. Underuse of postcesarean thromboembolism prophylaxis. Obstet Gynecol 2013; 122 (06) 1197-1204
• 7 Ghaji N, Boulet SL, Tepper N, Hooper WC. Trends in venous thromboembolism among pregnancy-related hospitalizations, United States, 1994-2009. Am J Obstet Gynecol 2013; 209 (05) 433.e1-433.e8
• 8 Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol 2015; 125 (01) 5-12
• 9 California Maternal Quality Care Collaborative. Improving Health Care Response to Maternal Venous Thromboembolism. 2018 . Accessed January 8, 2024 at: cmqcc.org/resources-toolkits/toolkits/improving-health-care-response-maternal-venous-thromboembolism
• 10 Gould MK, Garcia DA, Wren SM. et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (2 suppl): e227S-e277S
• 11 Palmerola KL, D'Alton ME, Brock CO, Friedman AM. A comparison of recommendations for pharmacologic thromboembolism prophylaxis after caesarean delivery from three major guidelines. BJOG 2016; 123 (13) 2157-2162
• 12 Sibai BM, Rouse DJ. Pharmacologic thromboprophylaxis in obstetrics: broader use demands better data. Obstet Gynecol 2016; 128 (04) 681-684
• 13 Kotaska A. Postpartum heparin thromboprophylaxis: more harm than good. Obstet Gynecol 2021; 138 (04) 527-529
• 14 Middleton P, Shepherd E, Gomersall JC. Venous thromboembolism prophylaxis for women at risk during pregnancy and the early postnatal period. Cochrane Database Syst Rev 2021; 3 (03) CD001689
• 15 Lu MY, Blanchard CT, Ausbeck EB. et al. Evaluation of a risk-stratified, heparin-based, obstetric thromboprophylaxis protocol. Obstet Gynecol 2021; 138 (04) 530-538
• 16 D'Alton ME, Friedman AM, Smiley RM. et al. National Partnership for Maternal Safety: Consensus bundle on venous thromboembolism. Anesth Analg 2016; 123 (04) 942-949
• 17 Alhazzani W, Lim W, Jaeschke RZ, Murad MH, Cade J, Cook DJ. Heparin thromboprophylaxis in medical-surgical critically ill patients: a systematic review and meta-analysis of randomized trials. Crit Care Med 2013; 41 (09) 2088-2098
• 18 Eikelboom JW, Karthikeyan G, Fagel N, Hirsh J. American Association of Orthopedic Surgeons and American College of Chest Physicians guidelines for venous thromboembolism prevention in hip and knee arthroplasty differ: what are the implications for clinicians and patients?. Chest 2009; 135 (02) 513-520
• 19 Lindqvist PG, Bremme K, Hellgren M. Working Group on Hemostatic Disorders (Hem-ARG), Swedish Society of Obstetrics and Gynecology. Efficacy of obstetric thromboprophylaxis and long-term risk of recurrence of venous thromboembolism. Acta Obstet Gynecol Scand 2011; 90 (06) 648-653
• 20 Ho KM, Tan JA. Stratified meta-analysis of intermittent pneumatic compression of the lower limbs to prevent venous thromboembolism in hospitalized patients. Circulation 2013; 128 (09) 1003-1020
• 21 Monti D, Wang CY, Yee LM, Feinglass J. Antepartum hospital use and delivery outcomes in California. Am J Obstet Gynecol MFM 2021; 3 (06) 100461
• 22 Brady MA, Carroll AW, Cheang KI, Straight C, Chelmow D. Sequential compression device compliance in postoperative obstetrics and gynecology patients. Obstet Gynecol 2015; 125 (01) 19-25
• 23 Merriam AA, Huang Y, Ananth CV, Wright JD, D'Alton ME, Friedman AM. Postpartum thromboembolism prophylaxis during delivery hospitalizations. Am J Perinatol 2018; 35 (09) 873-881
• 24 Friedman AM, Ananth CV, Prendergast E, Chauhan SP, D'Alton ME, Wright JD. Thromboembolism incidence and prophylaxis during vaginal delivery hospitalizations. Am J Obstet Gynecol 2015; 212 (02) 221.e1-221.e12
• 25 Craigie S, Tsui JF, Agarwal A, Sandset PM, Guyatt GH, Tikkinen KA. Adherence to mechanical thromboprophylaxis after surgery: A systematic review and meta-analysis. Thromb Res 2015; 136 (04) 723-726
• 26 Greenall R, Davis RE. Intermittent pneumatic compression for venous thromboembolism prevention: a systematic review on factors affecting adherence. BMJ Open 2020; 10 (09) e037036