Long-term quality of life after pregnancy-related deep vein thrombosis and the influence of socioeconomic factors and comorbidity

Effects of Deep Venous Thrombosis Treatments on Early and Long-term Quality of Life: Medical Therapy vs. Systemic Thrombolysis vs. Pharmacomechanical Thrombolysis

OBJECTIVES

The present study aimed to compare the effects of medical therapy (MT), systemic thrombolysis (ST), and pharmacomechanical thrombolysis (PMT) methods used in our clinic for the treatment of deep venous thrombosis (DVT) on symptom reduction, the incidence of post-thrombotic syndrome (PTS) development, and quality of life.

METHODS

Data from160 patients diagnosed with acute DVT between January 2012 and May 2021 and treated and followed up in our clinic were retrospectively analyzed. The patients were divided into three groups according to treatment method. The patients who received MT treatment were defined as Group 1, anticoagulant treatment after ST as Group 2, and anticoagulant treatment after PMT as Group 3. The patients were called to the outpatient clinic, informed consent was obtained, EuroQol-5D-3 L (EQ-5D-3 L) scoring and Villalta scoring were performed, and anamnesis was taken.

RESULTS

A total of 160 patients were included, with 71 (44.4%) patients in Group 1, 45 (28.1%) in Group 2, and 44 (27.5%) in Group 3. The mean age was 48.9 ± 14.9 years for Group 1, 42.2 ± 10.8 for Group 2, and 29.0 ± 7.2 for Group 3. When the time to return to normal life and the EQ-5D-3 L score index were compared, the differences between Groups 1 and 2 and between Groups 1 and 3 were statistically significant (P = .000 and P = .000, respectively). However, the differences between Groups 2 and 3 were statistically insignificant (P = .213 andp = .074, respectively). When Villalta scores and EQ Visual Analogue Scale (EQ-VAS) scores were compared between groups, the difference between all groups was statistically significant (P = .000).

CONCLUSIONS

The medical treatment alone was observed to be insufficient in terms of symptomatic improvement, development of PTS, quality of life, and long-term complications. When the ST and PMT groups were compared, it was determined that PMT treatment was more advantageous in terms of EQ-VAS score and PTS development, although there was no statistical difference regarding complications, such as return to normal life and long-term quality of life, the incidence of recurrent DVT development, and pulmonary thromboembolism incidence.

Patient-Reported Outcomes in Venous Thromboembolism: A Systematic Review of the Literature, Current Challenges, and Ways Forward

BACKGROUND

Venous thromboembolism (VTE) affects >1.2 million Americans annually. Although the clinical outcomes and economic burdens of VTE have been well described, the impact of VTE on patients' health status has yet to be summarized. This systematic review summarizes how patient-reported outcome measures (PROMs) have been used in VTE to date.

METHODS AND RESULTS

PubMed/MEDLINE was queried for literature published through March 2023 using PROMs in a population of patients with VTE. Studies were excluded if the reference was an editorial, review, or case report, or if the study included patients with conditions other than VTE. Qualitative analyses were performed. After screening and exclusion, 136 references were identified; 5 described PROM development, 20 focused on PROM validation, and 111 used PROMs in outcomes research. The most used generic PROMs were the 36-item Short-Form Health Survey and EuroQol 5-dimensional questionnaire, and the most common disease-specific PROMs were the Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Symptoms and the Pulmonary Embolism Quality of Life Questionnaire. PROMs were used to quantify the changes in health status after diagnosis, characterize the trajectory of subsequent improvement, and identify drivers of continued impairments in health status like postthrombotic syndrome and postpulmonary embolism syndrome. PROMs were also used to investigate the impact of novel treatment modalities on quality of life.

CONCLUSIONS

This review demonstrates the many benefits of PROM use, including quantifying changes in health status with treatment, capturing patients' experiences with the treatment itself, and identifying complications of VTE. Incorporating PROMs into VTE care will be an essential component of evaluating the effectiveness of novel therapies and should lead to improved shared decision-making for patients with VTE.

Endovascular Thrombus Removal for Treating Post-Partum Iliofemoral Deep Vein Thrombosis: A Single-Centre Retrospective Cohort Study

OBJECTIVE

To evaluate the safety and efficacy of percutaneous thrombectomy for treating postpartum iliofemoral vein thrombosis.

METHODS

A retrospective analysis was performed on patients with continuous postpartum acute symptomatic iliofemoral deep vein thrombosis who were treated in our center, including all patients who underwent pharmacomechanical thrombolysis (PMT) or only catheter-directed thrombolysis (CDT) (study group), and patients that received simple anticoagulation treatment (control group). We evaluated the incidence of lower extremity postthrombotic syndrome, recanalization rate of lower extremity veins, and complications in the study and control groups.

RESULTS

Overall, 72 postpartum women were included in this study, including the PMT combined with CDT group (14 cases, 15 limbs), CDT alone group (26 cases, 27 limbs), and anticoagulant therapy alone group (32 cases, 34 limbs). The thrombectomy group completed the treatment with a technical success rate of 100%, and no serious bleeding complications occurred. The patency rate of lower limb veins in the thrombectomy group was 85.09 ± 16.51% after treatment and 82.60 ± 21.45% after 1 year. At the 1-year follow-up, the Villalta score in the study group was lower (1.90 ± 2.45 vs 8.50 ± 5.33, P < .001), and the incidence of postthrombotic syndrome was significantly different between the groups (17.50% in the study group vs 68.75% in the anticoagulant group, P < .001).

CONCLUSIONS

Lower extremity venous thrombectomy is a safe and effective treatment for postpartum iliofemoral venous thrombosis. It can improve the patency rate of lower extremity veins and reduce the incidence of postthrombotic syndrome compared with anticoagulation alone.

Preventing Postpartum Venous Thromboembolism in 2022: A Narrative Review

The postpartum period represents the most critical time for pregnancy-associated venous thromboembolism (VTE), which is responsible for substantial morbidity and an important cause of maternal mortality. The estimated risk of postpartum VTE of about 1/1,000 deliveries can be modulated with the knowledge of maternal and obstetrical risk factors, although a precise estimate remains challenging in individuals. The use of postpartum low-dose low-molecular-weight heparins are tailored at intermediate and high-risk groups to reduce the thrombotic burden, despite the lack of dedicated randomized controlled trials. In this review, we will highlight the contemporary evidence on the risk of postpartum VTE, its stratification and its prevention. We will also discuss our knowledge on the values and preferences of women for postpartum thromboprophylaxis and their adherence to treatment.

Thrombophilia, Thrombosis and Thromboprophylaxis in Pregnancy: For What and in Whom?

Compared with nonpregnant women, pregnancy carries a four- to fivefold higher risk of venous thromboembolism (VTE). Despite increasing use of heparin prophylaxis in identified high-risk patients, pulmonary embolism still is the leading cause of maternal mortality in the western world. However, evidence on optimal use of thromboprophylaxis is scarce. Thrombophilia, the hereditary or acquired tendency to develop VTE, is also thought to be associated with complications in pregnancy, such as recurrent miscarriage and preeclampsia. In this review, the current evidence on optimal thromboprophylaxis in pregnancy is discussed, focusing primarily on VTE prevention strategies but also discussing the potential to prevent recurrent pregnancy complications with heparin in pregnant women with thrombophilia.

Quality of Life Status and Influencing Factors Among Patients with Deep Vein Thrombosis

OBJECTIVE

The objective of the study was to describe the quality of life (QoL) status and investigate the influencing factors of QoL among patients with deep vein thrombosis (DVT).

METHODS

A retrospective analysis at a single center was performed, and the clinical data of 161 patients with DVT admitted to West China Hospital of Sichuan University from June 2019 to June 2020 were collected with the Villalta scale, Hospital Anxiety and Depression Scale (HADS), and Chronic Venous Insufficiency Questionnaire (CIVIQ). The relationship between QoL and influencing factors, including characteristics, course of DVT, postthrombotic syndrome (PTS), psychological status, and behaviors, was analyzed by Student's t-test, analysis of variance and multiple linear regression.

RESULTS

A total of 161 patients who completed all the questionnaires between 2019 and 2020 were included, and 110 patients (68%) were male. The mean QoL score acquired by the CIVIQ scale was 74.18±8.44, and the results showed significant differences between patients of different ages, genders, behaviors and psychological statuses (P < 0.05). Multiple regression analysis showed that age (P = 0.024), negative mood (P < 0.001), CCI index (P < 0.001), PTS (P < 0.001) and regular exercise (P = 0.002) influenced the CIVIQ scale evaluation model, in which exercise regularly was a protective factor for QoL, and age, negative mood, CCI index and PTS were risk factors for QoL.

CONCLUSION

The QoL of DVT patients was impaired and associated with age, mood, CCI index and PTS. Regular exercise is beneficial for improving the quality of life of DVT patients.

Approach to the Evaluation and Treatment of Venous Thromboembolism in Pregnancy

Thrombosis in pregnancy is a major cause of maternal and fetal morbidity and mortality. Risk stratification of venous thromboembolism (VTE) during pregnancy is complex. The hypercoagulability observed in pregnant women can reduce bleeding during childbirth, but may cause thrombosis especially in the presence of additional prothrombotic risk factors such as antiphospholipid antibodies or genetic thrombophilic defects. The availability of large datasets allows for the identification of additional independent risk factors, including assisted reproductive technologies (ARTs), endometriosis, and recurrent pregnancy loss. Data on the risk of VTE linked to COVID-19 in pregnant women are very limited, but suggest that infected pregnant women have an increased risk of VTE. Current guidelines on the prevention and treatment of VTE in pregnancy are based on available, albeit limited, data and mainly present expert opinion. Low-molecular-weight heparins (LMWHs) are the mainstay of anticoagulation to be employed during pregnancy. Administration of LMWH for VTE treatment in pregnancy should be based on the personalized approach, taking into account a weight-based adjusted scheme. During gestation, due to physiological changes, in women at high risk of VTE, monitoring of anti-Xa activity is performed to ensure adequate LMWH dosing. As for the treatment duration for pregnant women with acute VTE, guidelines suggest that anticoagulation should be continued for at least 6 weeks postpartum for a minimum total duration of therapy of 3 months.

Risk factors for pregnancy-associated venous thromboembolism in Singapore

OBJECTIVES

Pregnancy-associated venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), is associated with increased risk of maternal mortality and morbidity. This study aimed to assess potential risk factors for pregnancy-associated VTE.

METHODS

In this case-control study, women with pregnancy-associated VTE were identified via International Classification of Diseases codes and included if they had been objectively diagnosed with VTE during pregnancy or within six weeks postpartum, from 2004 to 2016, at KK Women's and Children's Hospital or Singapore General Hospital in Singapore. Controls, i.e. pregnant women without VTE, were selected from a prospective longitudinal study. The odds ratio (OR) for VTE was computed for a range of maternal and obstetric factors.

RESULTS AND CONCLUSIONS

From 2004 to 2016, 89 cases of pregnancy-associated VTE and 926 controls were identifed and analysed using logistic regression. The most significant risk factors for pregnancy-associated VTE were smoking (OR 5.44, p=0.0002) and preterm delivery (OR 5.06, p=0.023). Malay race, multiparity, non-O blood group and caesarean section, were also identified to be of higher risk. These risk factors should be useful in the development of thromboprophylaxis strategies for pregnancy and the postpartum period, especially in Singapore.

Pulmonary Embolism in Pregnancy

Even though venous thromboembolism is a leading cause of maternal mortality in high-income countries, there are limited high-quality data to assist clinicians with the management of pulmonary embolism in this patient population. Diagnosis, prevention, and treatment of pregnancy-associated pulmonary embolism are complicated by the need to consider fetal, as well as maternal, well-being. Recent studies suggest that clinical prediction rules and D-dimer testing can reduce the need for diagnostic imaging in a subset of patients. Low-molecular-weight heparin is the preferred anticoagulant for both prophylaxis and treatment in this setting. Direct oral anticoagulants are contraindicated during pregnancy and in breastfeeding women. Thrombolysis or embolectomy should be considered for pregnant women with pulmonary embolism complicated by hemodynamic instability. Treatment of pregnancy-associated pulmonary embolism should be continued for at least 3 months, including 6 weeks postpartum. Management of anticoagulants at the time of delivery should involve a multidisciplinary individualized approach that uses shared decision making to take patient and caregiver values and preferences into account.

Combined thrombogenic effects of vessel injury, pregnancy and procoagulant immune globulin administration in mice

Background

Pregnant women are at increased risk of thrombotic adverse events. Plasma derived immune globulin (IG) products, which are used in pregnancy for various indications, may contain procoagulant impurity activated coagulation factor XI (FXIa). Procoagulant IG products have been associated with increased thrombogenicity but their effect in pregnancy is unknown.

Methods

Late pregnant (gestation days 17–20) or early lactation (days 1–3) and control female mice were treated with IGs supplemented with human FXIa then subjected to ferric chloride (FeCl₃) vessel injury. Occlusion of blood vessel was assessed by recording blood velocity in the femoral vein for 20 min using doppler ultrasound laser imaging. FXIa dose was selected by the ability to increase thrombin generation in mouse plasma in vitro.

Results

FXIa produced robust thrombin generation in mouse plasma ex vivo. Following FeCl₃ injury, pregnant and non-pregnant mice receiving IG + FXIa exhibited faster reduction of blood velocity in femoral vein compared to IG alone or untreated controls. In vitro, thrombin generation in plasma samples collected after thrombosis in FXIa-treated animals was elevated and could be reduced by anti-FXI antibody.

Conclusions

Our results suggest that intravenously-administered FXIa may contribute to thrombosis at the site of vascular injury in both pregnant and non-pregnant animals.

Supplementary Information

Supplementary information accompanies this paper at 10.1186/s12959-020-00245-8.

Pharmacomechanical catheter thrombolysis for pregnancy-related proximal deep venous thrombosis: prevention of post-thrombotic syndrome

OBJECTIVE

The efficacy of pharmacomechanical catheter-directed thrombolysis (PCDT) in preventing post thrombotic syndrome (PTS) for pregnancy related deep vein thrombosis (DVT) is unknown.

STUDY DESIGN

An observational cross section study of women with pregnancy related proximal (femoral/iliofemoral) DVT who underwent PCDT followed by anticoagulation (study group), and women who were treated with anticoagulation alone (control group). Women were evaluated for PTS using the Villalta scale (primary outcome) and VEINES-QOL/Sym questionnaires.

RESULTS

Eleven women with iliofemoral DVT underwent PCDT, two during their first trimester and nine postpartum; 18 women were treated with anticoagulation only. There were no significant differences in age, number of previous pregnancies, and duration of anticoagulation or thrombophilia between the groups. The time between DVT diagnosis and study inclusion was longer in the study group [median 50.5 (range 16-120) months] compared to the control group [median 27 (range 11-64) months], p = .4. None of the women in the PCDT group developed PTS, compared to six (33.3%, p = .03) in the control group, four of whom developed severe PTS. One patient in each group developed recurrent DVT, and one patient in the study group developed a calf hematoma. A reduced frequency of lower extremity symptoms was observed in the PCDT group (VEINES-Sym questionnaire), but no differences in quality of life (VEINES-QOL questionnaire) were reported.

CONCLUSION

This study suggests that PCDT may reduce the incidence of PTS in women with pregnancy related proximal DVT.Bullet pointsDVT involving the iliofemoral veins and development of post thrombotic syndrome is frequent among pregnant or postpartum womenStudies of pharmacomechanical catheter-directed thrombolysis (PCDT) for deep vein thrombosis did not include pregnant or postpartum womenIn our observational cross section study women who underwent PCDT (mainly in the postpartum period) had reduced frequency of post-thrombotic syndrome compared to women who received anticoagulation onlyLarger studies are required to confirm the use of PCDT for prevention of PTS in this population.

Psychotropic drug use following venous thromboembolism versus diabetes mellitus in adolescence or young adulthood: a Danish nationwide cohort study

OBJECTIVES

Critical and chronic illness in youth such as diabetes can lead to impaired mental health. Despite the potentially traumatic and life-threatening nature of venous thromboembolism (VTE), the long-term mental health of adolescents and young adults with VTE is unclear. We compared the long-term mental health of adolescents and young adults with VTE versus adolescents and young adults with insulin-dependent diabetes mellitus (IDDM) using psychotropic drug purchase as proxy for mental health.

DESIGN

Nationwide registry-based cohort study.

SETTING

Denmark 1997-2015.

PARTICIPANTS

All patients aged 13-33 years with an incident diagnosis of VTE (n=5065) or IDDM (n=6609).

EXPOSURE

First time primary hospital diagnosis of VTE or IDDM.

PRIMARY AND SECONDARY OUTCOME MEASURES

Adjusted absolute risk and risk difference at 1 and 5 years follow-up for first psychotropic drug purchase comparing patients with VTE and patients with IDDM.

RESULTS

The absolute 1 year risk of psychotropic drug use was 6.2% among VTE patients versus 3.6% among patients with IDDM, at 5 years this was 19.3%-14.7%, respectively. After adjusting for the effect of sex, age and risk factors for VTE this corresponded to a 1 year risk differences of 1.9% (95 % CI 0.1% to 3.3%). At 5 years follow-up the risk difference was 1.9% (95% CI 0.5% to 3.3%).

CONCLUSION

One-fifth of adolescents and young adults with incident VTE had claimed a prescription for a psychotropic drug within 5 years, a risk comparable to that of young patients with IDDM.

Long-term mental wellbeing of adolescents and young adults diagnosed with venous thromboembolism: results from a multistage mixed methods study

Essentials Long-term mental wellbeing of adolescents and young adults with venous thromboembolism is unclear. This multistage mixed methods study was based on Danish nationwide registry data and interviews. Mental wellbeing is negatively impacted in the long-term and uncertainty of recurrence is pivotal. The perceived health threat is more important than disease severity for long-term mental wellbeing.

SUMMARY

Background Critical and chronic illness in youth can lead to impaired mental wellbeing. Venous thromboembolism (VTE) is a potentially traumatic and life-threatening condition. Nonetheless, the long-term mental wellbeing of adolescents and young adults (AYAS) with VTE is unclear. Objectives To investigate the long-term mental wellbeing of AYAS (aged 13-33 years) diagnosed with VTE. Methods We performed a multistage mixed method study based on data from the Danish nationwide health registries, and semistructured interviews with 12 AYAS diagnosed with VTE. An integrated mixed methods interpretation of the findings was conducted through narrative weaving and joint displays. Results The integrated mixed methods interpretation showed that the mental wellbeing of AYAS with VTE had a chronic perspective, with a persistently higher risk of psychotropic drug purchase among AYAS with a first-time diagnosis of VTE than among sex-matched and age-matched population controls and AYAS with a first-time diagnosis of insulin-dependent diabetes mellitus. Impaired mental wellbeing was largely connected to a fear of recurrence and concomitant uncertainty. Therefore, it was important for the long-term mental wellbeing to navigate uncertainty. The perceived health threat played a more profound role in long-term mental wellbeing than disease severity, as the potential life threat was the pivot which pointed back to the initial VTE and forward to the perception of future health threat and the potential risk of dying of a recurrent event. Conclusion Our findings show that the long-term mental wellbeing of AYAS diagnosed with VTE is negatively affected, and highlights these patients' need for adequate support.

Long-term quality of life and postthrombotic syndrome in women after an episode of venous thromboembolism

Objectives To evaluate health-related quality of life after venous thromboembolism. Methods We conducted a cohort study, TEHS follow-up, including 1040 women with a first episode of venous thromboembolism and 994 women unexposed to venous thromboembolism. Patients were recruited from the "Thrombo Embolism Hormonal Study" (TEHS), a Swedish nation-wide case-control study on risk factors for venous thromboembolism in women 18-64 years of age. Quality of life was measured using SF-36 and VEINES-QoL/VEINES-Sym. Results On average there were no difference in mean SF-36 summary scales scores between exposed and unexposed women. Twenty percent of exposed women developed postthrombotic syndrome during follow-up. Women with postthrombotic syndrome had severely impaired quality of life with lower scores on all scales. Other predictors of low quality of life after venous thromboembolism were age, obesity, physical inactivity, and recurrent venous thromboembolism. Conclusion Long-term quality of life after venous thromboembolism in women was severely impaired among those developing postthrombotic syndrome, while quality of life in women not developing postthrombotic syndrome was similar to a control population.

Late consequences of venous thromboembolism: Measuring quality of life after deep vein thrombosis and pulmonary embolism

The identification of specific post-thrombotic complications as well as an increased appreciation of the importance of patient-reported outcome measures have triggered an interest in studying health-related quality of life (HRQoL) in patients with a history of venous thromboembolism (VTE). In order to enable a comprehensive assessment of HRQoL in clinical trials it is recommended that both generic and disease-specific questionnaires be used. SF-36 and EQ-5D are the most widely used generic questionnaires in VTE studies, whereas several disease-specific questionnaires have been developed to evaluate HRQoL following deep vein thrombosis (DVT) and in chronic venous disease (CVD). The most widely used of these is the VEINES-QOL/Sym, which was developed for CVD. VT-QOL and DVTQOL are both questionnaires developed to evaluate HRQoL after DVT, while PEmb-QoL is currently the only available disease-specific questionnaire developed specifically for pulmonary embolism (PE). Although studies show inconsistent results, patients who sustain DVT seem in general to report similar HRQoL compared to the general population. However, patients who develop PTS after DVT report poorer HRQoL using both generic and disease-specific questionnaires. HRQoL appears to be impaired in patients who sustain PE compared to the general population. In these patients, persistent dyspnea after PE has been shown to be a predictor of reduced HRQoL. Further work is needed to develop practical, patient-derived, valid, reliable and responsive disease-specific HRQoL instruments covering the specific aspects of these diseases.

Do pregnant women have a higher risk for venous thromboembolism following air travel?

International travel has become increasingly common and accessible, and it is part of everyday life in pregnant women. Venous thromboembolism (VTE) is a serious public health disorder that occurs following long-haul travel, especially after air travel. The normal pregnancy is accompanied by a state of hypercoagulability and hypofibrinolysis. Thus, it seems that pregnant women are at a higher risk of VTE following air travel, and, if they have preexisting risk factors, this risk would increase. There is limited data about travel-related VTE in pregnant women; therefore, in the present study, we tried to evaluate the pathogenesis of thrombosis, association of thrombosis and air travel, risk factors and prevention of VTE in pregnant women based on available evidences. Pregnancy is associated with a five- to 10-fold increased risk of VTE compared with nonpregnant women; however, during the postpartum period, this risk would increase to 20–80-fold. Furthermore, the risk of thrombosis is higher in individuals with preexisting risk factors, and the most common risk factor for VTE during pregnancy is a previous history of VTE. Pregnant women are at a higher risk for thrombosis compared with other women. Thus, the prevention of VTE and additional risk factors should be considered for all pregnant women who travel by plane.

Use of psychotropic drugs following venous thromboembolism in youth. A nationwide cohort study

INTRODUCTION

The mental health prognosis following a venous thromboembolism in youth has not been investigated comprehensively. Using psychotropic drug purchase as a proxy for mental health status, we investigated this issue in a large cohort of young incident venous thromboembolism patients.

METHODS

Using Danish nationwide administrative registries from the period 1997-2010, we identified 4,132 patients aged 13-33 years with a first-time venous thromboembolism diagnosis and no history of psychotropic drug usage. We sampled comparison cohort of random general population controls, matched individually in a 1:5 ratio based on sex and birth year. Participants were followed in prescription purchase registries for their first psychotropic drug purchase.

RESULTS

Among young venous thromboembolism case cases, the 1-year risk of psychotropic drug purchase was 7.1% (95% confidence interval [CI] 6.3, 7.9) and the 5-year risk 22.1% (95% CI 20.7, 23.5). This was substantially higher than among population controls, with 1- and 5-year risk differences relative to the controls of 4.7% (95% CI 3.9, 5.5), and 10.8% (95% CI 9.4, 12.3), respectively. Adjustment for the effects of recent pregnancy or somatic provocations attenuated risk differences to 4.1% (95% CI 3.5, 5.1) after 1 year and 9.6% (95% CI 8.3, 11.2) after 5 years.

CONCLUSIONS

A venous thromboembolism diagnosis in youth is associated with a poorer mental health prognosis: one in five patients are prescribed psychotropic medication within the first 5 year after diagnosis.

Racial and ethnic differences in the risk of postpartum venous thromboembolism: a population-based, case-control study

BACKGROUND

Venous thromboembolism (VTE) is a major contributor of maternal morbidity and mortality. Whether maternal race/ethnicity is associated with the risk of postpartum VTE remains unclear.

METHODS AND RESULTS

We conducted a population-based, case-control study in Washington State, from 1987 through 2011. Cases comprised all women with selected International Classification of Diseases, Ninth Edition, Clinical Modification codes for hospitalized VTE within 3 months post-delivery. Controls were randomly selected postpartum women who did not experience a VTE. Characteristics of women and their deliveries were abstracted from birth certificates. Using logistic regression models, we compared the risk of postpartum VTE in black, Asian, and Hispanic women with that in non-Hispanic white women, after adjustment for maternal characteristics (age, body mass index, parity, education), pregnancy complications, and delivery methods.

RESULTS

Our study comprised 688 cases and 10 246 controls. Among controls, the mean age and body mass index were 27.5 years and 26.3 kg m(-2) , respectively. Compared with white women, black and Asian women had a greater and lower risk of postpartum VTE (adjusted odds ratio [OR] 1.50, 95% confidence interval [CI] 1.10-2.04 and OR 0.67, 95%CI 0.48-0.94, respectively). A lower risk was present in Hispanic women (adjusted OR 0.80, 95% CI 0.61-1.06) but was not statistically significant. In subgroup analyses, we observed an increased risk for black compared with white women among women who delivered via cesarean section (OR 2.03, 95% CI 1.34-3.07) but not among vaginal deliveries (OR 1.03, 95% CI 0.61-1.74).

CONCLUSIONS

Maternal race/ethnicity is associated with the risk of postpartum VTE, independently of other risk factors, and should be considered when assessing the use of thromboprophylaxis after delivery.

A Systematic Review of Quality of Life Measures in Pregnant and Postpartum Mothers

Quality of life has emerged as an essential health component that broadens the traditionally narrow concerns focused on only morbidity and life expectancy. Although a growing number of tools to measure quality of life are in circulation, there is a lack of guidelines as well as rigorous assessment for their use with pregnant and postpartum populations. It is also unclear whether these instruments could validly be employed to measure patient-reported outcomes in comparative effectiveness research of maternal care interventions. This paper reviews articles cited in CINAHL, COCHRANE, EMBASE, PSYCINFO, and PUBMED that addressed quality of life in pregnant and postpartum populations. Instruments used to measure quality of life in selected articles were assessed for their adherence to international guidelines for health outcomes instrument development and validation. The authors identified 129 articles that addressed quality of life in pregnant and/or postpartum women. Out of these, only 64 quality (generic and specific) scales were judged relevant to be included in this study. Analysis of measurement scales used in the pregnant and/or postpartum populations revealed important validity, reliability and psychometric inadequacies that negate their use in comparative effectiveness analysis in pregnant and post-partum populations. Valid, reliable, and responsive instruments to measure patient-reported outcomes in pregnant and postpartum populations are lacking. To demonstrate the effectiveness of various treatment and prevention programs, future research to develop and validate a robust and responsive quality of life measurement scale in pregnant and postpartum populations is needed.

Women's views on and adherence to low-molecular-weight heparin therapy during pregnancy and the puerperium

BACKGROUND

Non-adherence to prescribed medication represents a significant factor associated with treatment failure. Pregnant women identified at risk of venous thromboembolism are increasingly being prescribed low-molecular-weight heparin (LMWH) during pregnancy and the puerperium. It is important to understand women's views on and adherence to LMWH during pregnancy and the puerperium, so that women gain maximum benefit from the treatment.

OBJECTIVES

To monitor women's adherence to enoxaparin, when prescribed during pregnancy and the puerperium, and explore their beliefs about the enoxaparin therapy prescribed.

PATIENTS/METHODS

A prospective cohort study involving 95 nullparous and multiparous women prescribed enoxaparin for recognized antenatal indications. Adherence to enoxaparin was assessed through self-completion of a diary, additionally verified through laboratory tests. An adapted beliefs about medication questionnaire was administered to women during their pregnancy.

RESULTS

Women were highly adherent to enoxaparin: antenatally, mean percentage adherence 97.92%; postnatally, mean percentage adherence 93.37% (paired t-test, P = 0.000). In the cohort of women we followed, their perceived necessity for enoxaparin therapy outweighed any concerns they had regarding enoxaparin antenatally, necessity-concerns differential 2.20. In some women, however, this perceived necessity does decrease postnatally.

CONCLUSIONS

Our results suggest that most women prescribed enoxaparin are highly adherent to their therapy during the antenatal period and that women's antenatal beliefs about enoxaparin are able to predict a decrease in postnatal adherence. Our results have important clinical implications, particularly when women are initiated on LMWH just during the postnatal period.

Long-term impact of pregnancy-related venous thrombosis on quality-of-life, general health and functioning: results of a cross-sectional, case-control study

OBJECTIVES

To evaluate the long-term consequences of pregnancy-related venous thrombosis (VT) by the assessment of generic quality-of-life (QOL), well-being, general health and daily-life functioning. We also wanted to evaluate the impact of the frequently occurring complication post-thrombotic syndrome (PTS) after that of deep vein thrombosis (DVT).

DESIGN

Population-based cross-sectional, case-control study.

SETTING

18 Norwegian hospitals during 1990-2003.

PARTICIPANTS

The study population comprised 559 cases with a validated first-ever, pregnancy-related VT and 1229 controls naïve for VT at the time of index pregnancy. Cases were identified using the Norwegian Patient Register and the Medical Birth Registry of Norway and the latter was used to select as controls women who gave birth at the same time as a case. After exclusion of two cases with missing location of VT, the final study population comprised 311 cases and 353 controls.

METHODS

Self-completion of a comprehensive questionnaire in 2006.

MAIN OUTCOME MEASURES

Generic QOL and well-being assessed by the Ferrans and Powers QOL Index (QLI) and the General Health Questionnaire (GHQ-20).

RESULTS

QOL assessed by QLI did not differ between cases and controls; mean score 23.1 (95% CI 22.7 to 23.5) vs 23.7 (23.3 to 24.0), neither did well being assessed by GHQ-20; 18.7 (18.0 to 19.4) vs 17.9 (17.3 to 18.4). However, cases reported pain other than in the lower limbs and muscle-skeletal problems more often and were more often physically worn out after work compared with controls. Cases which developed PTS reported poorer health, had pain more often, developed skin and psychiatric problems, used analgesic drugs more frequently and were more often on sick leave as compared to those without PTS.

CONCLUSIONS

Long-term generic QOL and subjective well-being 3-16 years after a pregnancy-related VT were not different from a reference population, but women with PTS after DVT seemed to have poorer QOL and an impaired general health.

Venous thromboembolism associated with pregnancy and hormonal therapy

Venous thromboembolism (VTE) is a major cause of maternal morbidity and mortality during or early after pregnancy and in women taking hormonal therapy for contraception or for replacement therapy. Post-thrombotic syndrome, including leg oedema and leg pain, is an unrecognized burden after pregnancy-related VTE, which will affect more than two of five women. Women with a prior VTE, a family history of VTE, certain clinical risk factors and thrombophilia are at considerably increased risk both for pregnancy-related VTE and for VTE on hormonal therapy. This review critically assesses the epidemiology and risk factors for pregnancy-related VTE and current guidelines for prophylaxis and treatment. We also provide information on the risk of VTE related to hormonal contraception and replacement therapy.