Venous thromboembolism after vaginal delivery rising, preventative measures lacking

1. Current rates of venous thromboembolism (VTE) prophylaxis during vaginal delivery hospitalizations are low, with patients having a history of VTE and/or hypercoagulability most likely to receive it.

2. Other risk factors for VTE such as obesity and smoking were not as strongly associated with VTE prophylaxis.

Evidence Rating Level: 2 (Good)

Study Rundown: Venous thromboembolism (VTE) is a common cause of pregnancy-related morbidity and mortality, and rates of VTE events have been increasing in the United States. VTE includes both deep vein thrombosis (DVT) and pulmonary embolism (PE). VTE is more common after cesarean delivery, and prevention of VTE in the U.S. has centered around cesarean deliveries. However, the majority of women undergo vaginal deliveries, and a greater proportion of VTE events occur among women delivering vaginally. Current guidelines for women undergoing vaginal deliveries recommend prophylaxis only for those women who are hypercoagulable and/or have had a prior thromboembolic event. VTE rates have been increasing over time. Some attribute this rise partially to increasing rates of medical risk factors including obesity, smoking and other chronic diseases, and prior work has produced some evidence to support this hypothesis. In the present study, authors found that current VTE prophylaxis practices are consistent with existing guidelines as described above; other known risk factors for VTE such as obesity are not strongly associated with use of prophylaxis. These findings suggest that there may be room to decrease the incidence of VTE by employing prophylaxis for women with multiple risk factors.

Limitations include retrospective design and use of claims data. Future studies exploring cost-effectiveness of VTE prophylaxis among patients with other risk factors are needed to determine whether and how national guidelines should be modified to decrease the incidence of VTE.

Click to read the study in AJOG

Relevant Reading: Thromboembolism in pregnancy: recurrence risks, prevention and management

In-Depth [retrospective cohort]: This study evaluated the incidence of VTE, defined as deep vein thrombosis (DVT) or pulmonary embolism (PE), and the use of mechanical or pharmacologic VTE prophylaxis among 2,673,986 women who were hospitalized for a vaginal delivery. Outcomes of interest were DVT, PE, and VTE events, as noted by ICD-9 codes on patient records.

Rates of VTE have increased between 2006 and 2012. Only 2.6% of women in the study received VTE prophylaxis; 67.5% of these women received mechanical prophylaxis in the form of graduated compression stockings or pneumatic compression devices. Patients with a history of VTE and hypercoagulability were more likely to receive prophylaxis (RR 10.14, CI 9.74-10.56 and RR 9.32, CI 8.96-9.71 respectively). Prophylaxis was more likely to occur in patients with other established risk factors for VTE, such as obesity (RR 1.29, CI 1.25-1.34).

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