1
|
Kayikci U, Fadiloglu E, Cigdem Bayrak A, Alptug Kir E, Esat Temiz B, Deren O. Guideline-based venous thromboprophylaxis in postpartum women: An in-depth evaluation of ACOG and RCOG recommendations and real-life implementation. Eur J Obstet Gynecol Reprod Biol 2024; 299:272-277. [PMID: 38924871 DOI: 10.1016/j.ejogrb.2024.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 06/13/2024] [Accepted: 06/16/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVES Venous thromboembolism is one of the most serious complications of the postpartum period, and international societies have various thromboprophylaxis guidelines for its prevention. This study compares postpartum venous thromboprophylaxis recommendations from the American College of Obstetrics and Gynecology (ACOG) and the Royal College of Obstetricians and Gynecologists (RCOG) with real-life clinical practices. STUDY DESIGN Data analysis of 1000 postpartum women at a tertiary care center focused on patient demographics, venous thromboembolism risk factors, and clinical thromboprophylaxis practices. Patient-specific risk factors were compared between ACOG and RCOG guidelines, assessing Low-Molecular-Weight-Heparin dosages and durations. Guideline compliance, undertreatment/overtreatment rates, and the required number of prefilled Low-Molecular-Weight-Heparin syringes were evaluated. RESULTS Significant discrepancies were observed between ACOG and RCOG guidelines, particularly in Low Molecular Weight Heparin dosages and durations. Consensus rates with clinical approaches were around 53%, with inconsistencies leaning towards undertreatment (RCOG) and overtreatment (ACOG). The number of required prefilled Low-Molecular-Weight-Heparin syringes was notably higher according to RCOG compared to ACOG guidelines. CONCLUSION Postpartum Venous thromboembolism prophylaxis guidelines from American College of Obstetrics and Gynecology and Royal College of Obstetricians and Gynecologists exhibit substantial differences, leading to variations in clinical practice. Further research on the significance of Venous thromboembolism risk factors is essential for improving risk assessment tools and refining guideline recommendations for pregnancy-related Venous thromboembolism prevention.
Collapse
Affiliation(s)
- Umutcan Kayikci
- Department of Obstetrics and Gynaecology, Division of Maternal Fetal Medicine and Perinatology, Hacettepe University Faculty of Medicine, Ankara, Turkey.
| | - Erdem Fadiloglu
- Department of Obstetrics and Gynaecology, Division of Maternal Fetal Medicine and Perinatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ayse Cigdem Bayrak
- Department of Obstetrics and Gynaecology, Division of Maternal Fetal Medicine and Perinatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Edip Alptug Kir
- Department of Obstetrics and Gynaecology, Division of Maternal Fetal Medicine and Perinatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Bilal Esat Temiz
- Department of Obstetrics and Gynaecology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ozgur Deren
- Department of Obstetrics and Gynaecology, Division of Maternal Fetal Medicine and Perinatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| |
Collapse
|
2
|
Federspiel JJ, Wein LE, Duggal R, Myers ER, Boggess KA, James AH. Projected impact of guidelines on incidence of venous thromboembolism after cesarean delivery in the United States. J Thromb Haemost 2023; 21:3547-3556. [PMID: 37659859 PMCID: PMC10840688 DOI: 10.1016/j.jtha.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 07/27/2023] [Accepted: 08/07/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND There is large variation in recommended for postcesarean delivery venous thromboembolism (VTE) prophylaxis among commonly used guidelines. OBJECTIVES The aim of the study is to estimate implications of adoption of VTE prevention guidelines for rates of receipt of VTE prophylactic therapy and VTE following cesarean delivery (CD). METHODS We used administrative data from the 2015-2019 Nationalwide Readmissions Database to identify cesarean deliveries and rates of VTE stratified by risk factors, leading to different prophylactic strategies based on several national guidelines. We used input parameters from the literature to construct a hybrid decision tree/Markov model to project the implications of guideline adoption on VTE rates for the first 6 weeks following delivery. RESULTS Adoption of either the 2011 American College of Obstetricians and Gynecologists or the 2018 American Society for Hematology guidelines would avert a relatively small proportion (5%) of VTE cases, albeit with little low-molecular-weight heparin (LMWH) use (87-115 doses per 1000 CD patients). The 2012 American College of Chest Physicians guidelines were predicted to be more effective at averting VTE (21.2% reduction) with more LMWH usage (570 doses per 1000 deliveries). The 2015 Royal College of Obstetricians and Gynaecologists guidelines and universal use of 6 weeks of LMWH would avert an even larger proportion of cases (37.4% and 57.6%, respectively), at the cost of much higher rates of LMWH utilization (7233 doses per 1000 patients and 38 648 doses per 1000 patients). CONCLUSIONS Adoption of different guidelines would have notably varying implications for clinical practice and potential for alteration of the national rate of VTE following CD.
Collapse
Affiliation(s)
- Jerome J Federspiel
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA; Department of Gynecology and Obstetrics, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
| | - Lauren E Wein
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ryan Duggal
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Evan R Myers
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kimberly A Boggess
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Andra H James
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| |
Collapse
|
3
|
Management of venous thromboembolism in pregnancy. Thromb Res 2022; 211:106-113. [DOI: 10.1016/j.thromres.2022.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/17/2022] [Accepted: 02/02/2022] [Indexed: 11/23/2022]
|
4
|
Skeith L. Prevention and management of venous thromboembolism in pregnancy: cutting through the practice variation. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:559-569. [PMID: 34889418 PMCID: PMC8791179 DOI: 10.1182/hematology.2021000291] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
There is clinical practice variation in the area of prevention and management of venous thromboembolism (VTE) in pregnancy. There are limited data and differing recommendations across major clinical practice guidelines, especially relating to the role of postpartum low-molecular-weight heparin (LMWH) for patients with mild inherited thrombophilia and those with pregnancy-related VTE risk factors. This chapter explores the issues of practice variation and related data for postpartum VTE prevention. Controversial topics of VTE management in pregnancy are also reviewed and include LMWH dosing and the role of anti-Xa level monitoring, as well as peripartum anticoagulation management around labor and delivery.
Collapse
Affiliation(s)
- Leslie Skeith
- Division of Hematology and Hematological Malignancies, Department of Medicine, Foothills Medical Centre, University of Calgary, Calgary, Canada
| |
Collapse
|
5
|
Gassmann N, Viviano M, Righini M, Fontana P, Martinez de Tejada B, Blondon M. Estimating the risk thresholds used by guidelines to recommend postpartum thromboprophylaxis. J Thromb Haemost 2021; 19:452-459. [PMID: 33176061 DOI: 10.1111/jth.15166] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 10/08/2020] [Accepted: 11/04/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Guidelines for postpartum thromboprophylaxis are mostly expert based. Acceptable postpartum venous thromboembolism (VTE) risk thresholds to justify the use of thromboprophylaxis are ill defined. OBJECTIVE To compare the proportion of postpartum women with recommended thromboprophylaxis according to the Royal College of Obstetricians and Gynecologists (RCOG), American College of Obstetricians and Gynecologists (ACOG), and American College of Chest Physicians (ACCP) guidelines, and to estimate their threshold of risk of VTE. METHODS We collected maternal, obstetrical, and fetal characteristics among all women who delivered at the Geneva University Hospitals in January 2019 through medical chart review. We determined for each woman the recommended strategy of thromboprophylaxis according to each guideline. We indirectly estimated individual absolute VTE risks using a validated risk prediction model (Sultan). RESULTS Among 344 women (mean age 32.2 years), with 23.3% of cesarean deliveries (CD), the RCOG guideline categorized 40.1% of all deliveries, 25.4% of vaginal deliveries (VD), and 88.8% of CD as requiring thromboprophylaxis. The ACOG and ACCP guidelines, which focus on CD, categorized fewer women as high risk (35.0% and 40.0% of CD, respectively). The mean estimated risk of VTE was 0.07% in all participants, 0.12% in those with recommended thromboprophylaxis according to the RCOG, and 0.20% among women after CD with recommended thromboprophylaxis by the ACOG and ACCP guidelines. CONCLUSIONS Our data highlight important variations in the proportion of thromboprophylaxis recommendation between guidelines. Risk thresholds to recommend the use of heparin appear very low, and may correlate with a high, and perhaps undesirable, number needed to treat to prevent VTE events.
Collapse
Affiliation(s)
| | - Manuela Viviano
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Obstetrics, Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - Marc Righini
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Angiology and Hemostasis, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre Fontana
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Angiology and Hemostasis, Geneva University Hospitals, Geneva, Switzerland
| | - Begoña Martinez de Tejada
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Obstetrics, Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - Marc Blondon
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Angiology and Hemostasis, Geneva University Hospitals, Geneva, Switzerland
| |
Collapse
|
6
|
O'Shaughnessy F, O'Reilly D, Ní Áinle F. Current opinion and emerging trends on the treatment, diagnosis, and prevention of pregnancy-associated venous thromboembolic disease: a review. Transl Res 2020; 225:20-32. [PMID: 32554071 DOI: 10.1016/j.trsl.2020.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 05/10/2020] [Accepted: 06/09/2020] [Indexed: 12/23/2022]
Abstract
Pregnancy associated venous thromboembolism (PA-VTE) is a leading cause of maternal morbidity and mortality worldwide. Despite the availability of international guidance on the prevention, diagnosis and treatment, practice differs between countries and clinical institutions. The evidence base in this area is limited due to the vulnerable population who are affected, with the majority of guidelines deriving their recommendations from experience in surgical and medical venous thromboembolic disease. This review includes best evidence in PA-VTE management, highlighting specific literature which supports current diagnosis, prevention, and treatment strategies. Additionally, we hope to demonstrate emerging trends in the field through discussion of ongoing trials designed to progress towards evidence-based practice in the context of PA-VTE.
Collapse
Affiliation(s)
- Fergal O'Shaughnessy
- Pharmacy Department, Rotunda Hospital, Dublin 1, Ireland; Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland; Department of Haematology, Mater University Hospital, Dublin 7, Ireland
| | - Daniel O'Reilly
- Department of Paediatrics, Children's Health Ireland at Tallaght, Dublin 24, Ireland; SPHERE research group, Conway Institute, University College Dublin, Dublin 4, Ireland; Department of Haematology, Mater University Hospital, Dublin 7, Ireland.
| | - Fionnuala Ní Áinle
- SPHERE research group, Conway Institute, University College Dublin, Dublin 4, Ireland; School of Medicine, University College Dublin, Dublin 4, Ireland; Department of Haematology, Rotunda Hospital, Dublin 1, Ireland; Department of Haematology, Mater University Hospital, Dublin 7, Ireland
| |
Collapse
|
7
|
Lamont MC, McDermott C, Thomson AJ, Greer IA. United Kingdom recommendations for obstetric venous thromboembolism prophylaxis: Evidence and rationale. Semin Perinatol 2019; 43:222-228. [PMID: 30935752 DOI: 10.1053/j.semperi.2019.03.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Venous thromboembolism (VTE) is a leading cause of maternal death in the United Kingdom. To address this problem guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) has been developed that recommends the assessment of a woman's risk of thrombosis at specific time-points during pregnancy and postnatally at the time of delivery. The RCOG guidelines provide clinicians with a framework to inform decision-making on the use of thromboprophylaxis and are based on the premise that the higher risk a woman has for VTE, the more likely she is to benefit from prophylaxis - determining her level of risk is based on the number and characteristics of the risk factors that she has. This article will address the pathophysiology of VTE in pregnancy, evidence behind the risk factors for VTE and the use of thromboprophylactic agents. Further, it will reflect on the rationale behind the RCOG guidance.
Collapse
Affiliation(s)
- M Christy Lamont
- Department of Obstetrics & Gynaecology, NHS Greater Glasgow & Clyde, Scotland
| | | | - Andrew J Thomson
- Department of Obstetrics & Gynaecology, NHS Greater Glasgow & Clyde, Scotland.
| | - Ian A Greer
- President and Vice Chancellor, Queen's University Belfast, Northern Ireland
| |
Collapse
|
8
|
Utilization of venous thromboembolism prophylaxis in American hospitalized pregnant women undergoing cesarean section. Int J Clin Pharm 2019; 41:264-271. [PMID: 30661217 DOI: 10.1007/s11096-018-00779-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 12/31/2018] [Indexed: 10/27/2022]
Abstract
Background Pregnancy-related venous thromboembolism (VTE) is a leading preventable cause of maternal mortality in the United States; however, American guidelines for pharmacologic VTE prophylaxis remain less aggressive than other developed countries. The Safe Motherhood Initiative (SMI) combines aspects of American and international guidelines to increase utilization of prophylaxis and thereby decrease incidence of pregnancy-related VTE. Objectives To evaluate the prescribing and administration rates of pharmacologic VTE prophylaxis for women undergoing cesarean section (c-section) when retrospectively applying the SMI recommendations. Setting Large academic medical center in Sacramento, California, USA. Method This was a single-center retrospective cohort study of pregnant women undergoing c-section who would have met criteria for pharmacologic prophylaxis according to the SMI. Main outcome measures Prescribing and administration rates of mechanical and pharmacologic VTE prophylaxis. Secondary outcomes included incidence of thromboembolism within 6 weeks after c-section and thromboembolic associated mortality. Results A total of 616 charts were analyzed. When applying the SMI guidelines for VTE prophylaxis, the prescribing rates for mechanical and pharmacologic prophylaxis were 94.3% and 4.71% of patients, respectively, and 94.9% of ordered pharmacologic prophylaxis doses were administered. The incidence of 6-week post-partum VTE was 0.49%. There were no cases of VTE-associated mortality. Conclusion This study demonstrated that a large population of c-section patients fit the SMI criteria for pharmacologic VTE prophylaxis but did not receive it. We observed a 0.49% rate of VTE, which was slightly higher than the nationally reported average rate of 0.3%. With growing rates of pregnancy-associated VTE in the United States, perhaps a more aggressive guideline is warranted.
Collapse
|
9
|
Abstract
Coagulation is an organized and well-orchestrated process that depends on the intrinsic balance between procoagulants, anticoagulants, and fibrinolytic systems. During pregnancy, this balance is affected in various ways and becomes more critical due to the physiologic changes and obligate hemorrhage after delivery. In some instances, this equilibrium will be disrupted. In this article, we describe the anesthetic implications of bleeding disorders, thrombophilias, and anticoagulation for the safe management of the parturient, with an emphasis on how this impacts decision-making by the anesthesiologist.
Collapse
Affiliation(s)
| | - Andrew Eisenberger
- Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York, NY
| |
Collapse
|
10
|
Wu P, Poole TC, Pickett JA, Bhat A, Lees CC. Current obstetric guidelines on thromboprophylaxis in the United Kingdom: evidence based medicine? Eur J Obstet Gynecol Reprod Biol 2013; 168:7-11. [DOI: 10.1016/j.ejogrb.2012.12.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 12/03/2012] [Accepted: 12/24/2012] [Indexed: 10/27/2022]
|