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Utilization of venous thromboembolism prophylaxis in American hospitalized pregnant women undergoing cesarean section

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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.

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References

  1. Khan KS, Wojdyla D, Say L, Gulmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet. 2006;367(9516):1066–74.

    Article  PubMed  Google Scholar 

  2. Pomp ER, Lenselink AM, Rosendaal FR, Doggen CJ. Pregnancy, the postpartum period and prothrombotic defects: risk of venous thrombosis in the MEGA study. J Thromb Haemost. 2008;6(4):632–7.

    Article  CAS  PubMed  Google Scholar 

  3. Chang J, Elam-Evans LD, Berg CJ, Herndon J, Flowers L, Seed KA, et al. Pregnancy-related mortality surveillance–United States, 1991–1999. MMWR Surveill Summ. 2003;52(2):1–8.

    PubMed  Google Scholar 

  4. 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(1):5–12.

    Article  Google Scholar 

  5. Kassebaum NJ, Barber RM, Dandona L, Hay SI, Larson HJ, Liang X, et al. Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388(10053):1775–812.

    Article  Google Scholar 

  6. D’Alton ME, Friedman AM, Smiley RM, Montgomery DM, Paidas MJ, D’Oria R, et al. National partnership for maternal safety: consensus bundle on venous thromboembolism. J Obstet Gynecol Neonatal Nurs. 2016;45(5):706–17.

    Article  PubMed  Google Scholar 

  7. Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO. VTE, thrombophilia, antithrombotic therapy, and pregnancy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 Suppl):e691S–736S.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Sultan AA, Tata LJ, West J, Fiaschi L, Fleming KM, Nelson-Piercy C, et al. Risk factors for first venous thromboembolism around pregnancy: a population-based cohort study from the United Kingdom. Blood. 2013;121(19):3953–61.

    Article  CAS  PubMed  Google Scholar 

  9. James A. Practice bulletin no. 123: thromboembolism in pregnancy. Obstet Gynecol. 2011;118(3):718–29.

    Article  PubMed  Google Scholar 

  10. Blondon M, Casini A, Hoppe KK, Boehlen F, Righini M, Smith NL. Risks of venous thromboembolism after cesarean sections: a meta-analysis. Chest. 2016;150(3):572–96.

    Article  PubMed  Google Scholar 

  11. Main EK, McCain CL, Morton CH, Holtby S, Lawton ES. Pregnancy-related mortality in California: causes, characteristics, and improvement opportunities. Obstet Gynecol. 2015;125(4):938–47.

    Article  PubMed  Google Scholar 

  12. Friedman AM, Ananth CV, Lu YS, D’Alton ME, Wright JD. Underuse of postcesarean thromboembolism prophylaxis. Obstet Gynecol. 2013;122(6):1197–204.

    Article  PubMed  Google Scholar 

  13. Cantwell R, Clutton-Brock T, Cooper G, Dawson A, Drife J, Garrod D, et al. Saving mothers’ lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The eighth report of the confidential enquiries into maternal deaths in the United Kingdom. BJOG. 2011;118(Suppl 1):1–203.

    PubMed  Google Scholar 

  14. RCOG. Reducing the risk of venous thromboembolism during pregnancy and the puerperium. Green-top Guideline. 2015;No. 37a. London: RCOG.

  15. Horlocker TT, Wedel DJ, Rowlingson JC, Enneking FK, Kopp SL, Benzon HT, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine evidence-based guidelines (third edition). Reg Anesth Pain Med. 2010;35(1):64–101.

    Article  CAS  Google Scholar 

  16. 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. 2015;123:2157–62.

    Article  PubMed  Google Scholar 

  17. Friedman AM, D’Alton ME. Venous thromboembolism bundle: risk assessment and prophylaxis for obstetric patients. Semin Perinatol. 2016;40(2):87–92.

    Article  PubMed  Google Scholar 

  18. Hameed AB, Friedman AM, Peterson N, Morton CH, Montgomery DM. Improving health care response to maternal venous thromboembolism. (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care) Developed under contract #11-10006 with the California Department of Public Health; Maternal, Child and Adolescent Health Division; Published by the California Maternal Qualit yCare Collaborative. 2018.

  19. James AH, Bushnell CD, Jamison MG, Myers ER. Incidence and risk factors for stroke in pregnancy and the puerperium. Obstet Gynecol. 2005;106(3):509–16.

    Article  PubMed  Google Scholar 

  20. James AH, Jamison MG, Brancazio LR, Myers ER. Venous thromboembolism during pregnancy and the postpartum period: incidence, risk factors, and mortality. Am J Obstet Gynecol. 2006;194(5):1311–5.

    Article  PubMed  Google Scholar 

  21. Abdul Sultan A, Grainge MJ, West J, Fleming KM, Nelson-Piercy C, Tata LJ. Impact of risk factors on the timing of first postpartum venous thromboembolism: a population-based cohort study from England. Blood. 2014;124(18):2872–80.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Blondon M. Thromboprophylaxis after cesarean section: decision analysis. Thromb Res. 2011;127(Suppl 3):S9–12.

    Article  CAS  PubMed  Google Scholar 

  23. Tepper NK, Boulet SL, Whiteman MK, Monsour M, Marchbanks PA, Hooper WC, et al. Postpartum venous thromboembolism: incidence and risk factors. Obstet Gynecol. 2014;123(5):987–96.

    Article  PubMed  Google Scholar 

  24. Blondon M, Perrier A, Nendaz M, Righini M, Boehlen F, Boulvain M, et al. Thromboprophylaxis with low-molecular-weight heparin after cesarean delivery. Thromb Haemost. 2010;103(1):129–37.

    Article  CAS  PubMed  Google Scholar 

  25. Jacobsen AF, Skjeldestad FE, Sandset PM. Ante- and postnatal risk factors of venous thrombosis: a hospital-based case-control study. J Thromb Haemost. 2008;6(6):905–12.

    Article  CAS  PubMed  Google Scholar 

  26. Nutescu EA, Spinler SA, Wittkowsky A, Dager WE. Low-molecular-weight heparins in renal impairment and obesity: available evidence and clinical practice recommendations across medical and surgical settings. Ann Pharmacother. 2009;43(6):1064–83.

    Article  CAS  PubMed  Google Scholar 

  27. Vandiver JW, Ritz LI, Lalama JT. Chemical prophylaxis to prevent venous thromboembolism in morbid obesity: literature review and dosing recommendations. J Thromb Thrombolysis. 2016;41(3):475–81.

    Article  CAS  PubMed  Google Scholar 

  28. Leffert LR, Dubois HM, Butwick AJ, Carvalho B, Houle TT, Landau R. Neuraxial anesthesia in obstetric patients receiving thromboprophylaxis with unfractionated or low-molecular-weight heparin: a systematic review of spinal epidural hematoma. Anesth Analg. 2017;125(1):223–31.

    Article  PubMed  Google Scholar 

  29. Roshani S, Cohn DM, Stehouwer AC, Wolf H, van der Post JA, Buller HR, et al. Incidence of postpartum haemorrhage in women receiving therapeutic doses of low-molecular-weight heparin: results of a retrospective cohort study. BMJ Open. 2011;1(2):e000257.

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

The authors would like to thank Jana Avila of UC Davis Health for her data abstraction assistance.

Funding

No funding was received.

Conflicts of interest

The authors declare that they have no conflict of interest.

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Authors and Affiliations

  1. Department of Clinical Pharmacy, University of California, San Francisco, 2315 Stockton Blvd, Sacramento, CA, 95817, USA

    Tiffany K. Pon

  2. Department of Obstetrics and Gynecology, Dignity Health, 8220 Wymark Dr, Ste 200, Elk Grove, CA, 95757, USA

    Natalie Wessel

  3. California Poison Control System, University of California, Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA, 95817, USA

    Vincent Cagonot

  4. Department of Pharmacy, University of California, San Diego Health, 200 W Arbor Dr, San Diego, CA, 92103, USA

    Ronnie Delmonte

  5. Department of Pharmacy Services, University of California, Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA, 95817, USA

    Denise Roach

  6. Department of Obstetrics and Gynecology, University of California, Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA, 95817, USA

    Laurel Finta

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  1. Tiffany K. Pon
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  2. Natalie Wessel
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  3. Vincent Cagonot
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Correspondence to Tiffany K. Pon.

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Pon, T.K., Wessel, N., Cagonot, V. et al. Utilization of venous thromboembolism prophylaxis in American hospitalized pregnant women undergoing cesarean section. Int J Clin Pharm 41, 264–271 (2019). https://doi.org/10.1007/s11096-018-00779-y

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  • DOI: https://doi.org/10.1007/s11096-018-00779-y

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