Pharmacological anti-thrombotic prophylaxis after elective caesarean delivery in thrombophilia unscreened women: should maternal age have a role in decision making? (original) (raw)
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Australian & New Zealand Journal of Obstetrics & Gynaecology, 2015
Background: Caesarean section (CS) is a significant risk factor for venous thromboembolism; however, the optimal method of thromboprophylaxis around the time of CS is unknown. Aims: To examine current thromboprophylaxis practice during and following CS in Australia and New Zealand, and the willingness of obstetricians to participate in a randomised controlled trial (RCT) comparing different methods of thromboprophylaxis after CS. Materials and Methods: An online survey was sent to fellows and trainees of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Results: There were 488 responses from currently practising obstetricians (response rate 23.4%). During CS, 48% and 80% of obstetricians recommended intermittent pneumatic compression (IPC) and elastic stockings (ES), respectively. Following CS, 96-97% of obstetricians recommended early ambulation, 87-90% recommended ES, 23-36% recommended IPC, and 42-65% recommended low molecular weight heparin (LMWH) depending on clinical factors. Increased BMI (OR 3.42; 95% CI 2.87-4.06), emergency CS (OR 1.88; 95% CI 1.67-2.16) and older maternal age (OR 1.37; 95% CI 1.26-1.49) were associated with more frequent LMWH use. Of obstetricians who prescribed LMWH, 70% adjusted the dose depending on maternal weight. LMWH therapy was most commonly recommended until discharge from hospital (31%), <5 days (24%) and 5-7 days (15%). Most obstetricians (58-79%) were willing to enrol women in a RCT, but less likely if the woman had an increased BMI or emergency CS. Conclusions: There is considerable variation in clinical practice regarding thromboprophylaxis during and following CS. Obstetricians support a RCT to assess different methods of thromboprophylaxis following CS.
Thromboprophylaxis following cesarean section – a nation-wide survey from Germany
The Journal of Maternal-Fetal & Neonatal Medicine, 2019
Objective: Our study aimed to assess current practice related to thromboprophylaxis following cesarean section (c.s.) among obstetricians in Germany taking account of the German and international guidelines. Study design: A nationwide survey using a structured 22-item questionnaire was conducted in Germany. The questionnaire was sent to head of all registered departments of obstetrics and gynecology in Germany, followed by a single reminder followed 3 weeks after the first return deadline. The respondents' answers were related to the different levels of care (1-4) of German perinatal centers. Results: In total 726 obstetric departments were invited to participate. Questionnaires were returned by 389 (54%) of departments. Of the respondents 162 (41%) stated to undertake risk assessment for venous thromboembolism (VTE) using a structured checklist or interview. Compared to level 4 centers risk assessment was significantly more often performed by perinatal centers level 1 (47 versus 35%, p ¼ .05). The majority of responding hospitals preferred universal heparin thromboprophylaxis following elective and emergency caesarean section, regardless of additional risk factors (n ¼ 362; 93%). The "usual" prophylactic dose of heparin was given by the majority of hospitals (n ¼ 280, 72%), while 98 (25%) hospitals used heparin doses adjusted to patients' body weight. In women at increased risk for VTE (e.g. previous VTE) there was a considerable variation in the recommended doses; 140 responding hospitals (36%) used 50-75% of the therapeutic heparin dose, 139 hospitals (36%) the "usual" prophylactic dose, and 97 hospitals (25%) preferred a therapeutic dose. In women at low risk for VTE 64% (n ¼ 248) of hospitals recommended heparin thromboprophylaxis only during the hospital stay, 16% (n ¼ 62) for at least 7 days after c.s., 4% (n ¼ 15) for 10 days, 6% (n ¼ 23) for 2-5 weeks, and 3% (n ¼ 14) for 6 weeks postpartum. In women at increased risk level 1 centers prescribed heparin for VTE prophylaxis significantly more often for 6-8-week postpartum compared to level 4 centers (p ¼ .02) whereas Level 4 centers used prophylactic heparin significantly more often <6 weeks (p ¼ .01). Conclusion: Our survey reveals that the vast majority of hospitals (93%) used heparin prophylaxis after any c.s., irrespective of individual risk factors and the mode of c.s. (elective or emergency). This is in remarkable contrast to the recommendations from the German and other international guidelines. As well, we found a wide variation among respondents in dosing and duration of heparin related to the risk profile of VTE. This demonstrates, that there is little awareness and/or adherence to the German and other guideline recommendations which mirrors the inconsistencies between current guidelines. There is an urgent need to clarify optimal prophylaxis strategies after c.s. and the true magnitudes of benefits and harms associated with heparin prophylaxis by randomized controlled trials with sufficient statistical power.
Thromboembolism Prophylaxis after Cesarean Section
Bahrain medical bulletin, 2018
The incidence of VTE in pregnancy is ten times higher than the age-matched, non-pregnant population 1-3. VTE could occur at any stage of pregnancy, but the risk is higher at the puerperium 1,4. VTE continues to be a leading cause of maternal mortality 5-7. Pulmonary embolism (PE) is the leading cause of maternal death in the United Kingdom, accounting for approximately 1.8 per 100,000 deliveries and 11% of maternal deaths in the United States 5-9. PE is the second leading cause of maternal death in Saudi Arabia, accounting for 25% of all maternal deaths 10. In Bahrain, PE is accounting for 35% of all maternal deaths in sickle cell disease (SCD) patients, as well as 21% of non-SCD 11,12. CS is a recognized risk factor for VTE 13. Hence, thromboprophylaxis is recommended for women undergoing CS following risk assessment 13-15. The patients were divided into three groups according to their risks: lower risk, intermediate risk and high risk. Lower risks require only early ambulation
Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstétrique et gynécologie du Canada : JOGC, 2008
To assess physician compliance, before and after a quality improvement intervention, with a regional policy on postpartum thromboprophylaxis following Caesarean section (CS), and to compare clinical outcomes (reduction of venous thromboembolism or increase in postpartum bleeding) between groups. We performed a retrospective chart review of deliveries by CS, 404 prior to and 451 subsequent to a quality improvement intervention. All subjects were classified as being at either moderate or high risk for venous thromboembolism based on a risk-factor assessment, and warranted postpartum thromboprophylaxis according to the regional policy. Data regarding thromboembolism risk factors, postpartum thromboprophylaxis received, and clinical outcomes were recorded. Initial compliance with the regional policy was poor, but improved following the intervention. The use of intermittent pneumatic compression devices increased from 32% to 84% (P < 0.001), use of anticoagulation increased from 6.2% ...
Thrombosis prophylaxis after treatment during pregnancy
European Journal of Obstetrics & Gynecology and Reproductive Biology, 1997
Deep vein thrombosis (DVT) is not a rare occurrence during pregnancy and puerperium due to changes in the coagulation mechanism. Eighteen cases with DVT during pregnancy are presented here. All of them received subcutaneous heparin for two weeks at a dose adjusted so as to prolong the activated partial thromboplastin time, or plasma recalcification time, to twice that of normal controls. Treatment continued with low molecular weight heparin (LMWH), once daily subcutaneously, for the duration of pregnancy and for one month postpartum. All women went into labor uneventfully, except for one who had a missed abortion during the t0th week. No side-effects were observed. LMWH has some advantages compared with standard heparin, which make it the treatment of choice for the prevention of thromboembolic events in pregnant women.
The Obstetrician & Gynaecologist, 2006
• Pregnancy and the puerperium are important risk factors for venous thromboembolism, but the presence of thrombophilia and a history of previous thrombosis are of greater significance. • Selective screening in pregnancy of women with a personal or family history of thrombosis or a history of poor pregnancy outcome may be of value, as around 50% of such women will have acquired or inherited thrombophilia. • There is a broad international agreement that low molecular weight heparin is the anticoagulant of choice in pregnancy,based on its widespread use over the last 10 years. Learning objectives: • To know the risk factors for venous thromboembolism in pregnancy. • To be able to ascertain who should be screened during pregnancy. • To be able to prescribe the most appropriate thromboprophylaxis in the antepartum and postpartum periods.
A review of caesarean section techniques and postoperative thromboprophylaxis at a tertiary hospital
Singapore medical journal, 2016
Although caesarean sections are among the most commonly undertaken procedures in the world, there are wide variations in the surgical techniques used for this procedure. This study aimed to: (a) review the surgical techniques used for caesarean sections by obstetricians working in a tertiary hospital in Singapore; (b) compare the techniques used by these surgeons with those recommended in evidence-based guidelines; and (c) examine the relationship between the technique used and the level of seniority of the surgeons. Data on 490 caesarean sections performed in Singapore General Hospital (SGH) between 1 August 2013 and 30 June 2014 was collected from the Delivery Suite database and reviewed. The surgical techniques studied were closure of the visceral and parietal peritoneum, closure of the uterine layer, use of surgical drains, and use of postoperative thromboprophylaxis. A total of 486 caesarean sections were analysed (4 of the 490 caesarean sections reviewed were excluded due to m...
The Obstetrician & Gynaecologist, 2007
• The diagnosis of venous thromboembolism requires objective testing, which can be done safely throughout pregnancy. • Low molecular weight heparin is the most suitable agent for both prophylaxis and treatment of venous thromboembolism in pregnancy. • Once labour has commenced, heparin should not be administered. • It is recommended that anticoagulants be resumed 4-6 hours after vaginal delivery and 6-12 hours after caesarean delivery. Learning objectives: • To be able to choose the most appropriate diagnostic tests for venous thromboembolism in pregnancy. • To be able to prescribe the most appropriate anticoagulants. • To be able to manage women on anticoagulants appropriately during the different stages of pregnancy. Ethical issues: • The risks to the fetus of anticoagulant therapy are outweighed by the health benefits to the mother. • Women of reproductive age on oral anticoagulants should know about warfarin embryopathy.
Thromboembolism following cesarean section: a retrospective study
Hematology, 2017
Objectives: As thromboembolism (TE) continues to be one of the principal causes of death in obstetrical patients and as the postpartum period is associated with the highest risk for TE, we sought to determine the risk factors associated with TE following cesarean section (CS). Methods: A retrospective analysis of patients who had CS at a large tertiary referral center was conducted. Patients were identified through hospital medical records and were contacted approximately 1 year following their CS. Medical records and a questionnaire were used to identify features that were potentially associated with TE. Univariate analysis was used to determine the risk associated with these characteristics. Results: A total of 2206 patients had a CS, of which 1377 (62%) participated. Of the respondents, 137 patients received heparin (94% received a prophylactic dose, 6% received a therapeutic dose) and the remainder, 1233 patients, did not receive heparin. Seven patients (0.5%) developed a TE and 86% developed a TE within 7 days of CS. The odds ratio (OR) for TE for women with hypertension prior to pregnancy compared to patients who did not receive anticoagulation was 21.28 [95% confidence interval (CI) 4.64-90.13] and for patients who had varicose veins with superficial thrombophlebitis when compared to patients who had received heparin postpartum was 21.01 (95% CI 1.55-288.24). Discussion: Hypertension and the presence of varicose veins were associated with TE following CS. Larger cohort analyses are required to confirm these associations so that risk scores incorporating these characteristics may accurately predict the occurrence of TE.