North American Physician Practice Patterns in the Management of Anticoagulation in Pregnancy

A comparison of international clinical practice guidelines for postpartum venous thromboembolism prophylaxis

BACKGROUND

Venous thromboembolism is a leading cause of maternal death worldwide. The postpartum period is a time of particularly increased risk. International guidelines provide recommendations for when a woman should be offered thromboembolism prophylaxis, however they differ greatly in their criteria as to which women qualify for low molecular weight heparin (LMWH). The aim of this study was to determine the most common risk factors for women being recommended LMWH and compare the proportion of women who would qualify for postpartum LMWH according to four international guidelines.

MATERIALS AND METHODS

This cross-sectional study evaluated rates of postpartum LMWH prophylaxis by applying guideline recommendations from the American College of Chest Physicians (ACCP), the Royal College of Obstetricians and Gynaecologists (RCOG), the Society of Obstetricians and Gynaecologists of Canada (SOGC) and the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ). Demographic, medical and obstetric risk factors for venous thromboembolism were identified for individual women from one regional and two tertiary maternity hospitals in New South Wales, Australia between February and October 2022.

RESULTS

A total of 338 women were included in the analyses. By applying RCOG guidelines, 53.6% of women would have qualified for postpartum LMWH compared with 40.2% of women using SOMANZ guidelines, 37.3% using SOGC guidelines, and 8.3% using ACCP guidelines. The most common risk factors were caesarean birth, maternal age greater than 35 years, body mass index above 30 kg/m2 and instrumental birth.

CONCLUSIONS

There are considerable differences in the rates of women receiving postpartum pharmacological venous thromboembolism prophylaxis when recommendations from different international guidelines are applied. These differences reflect the wide variation in guideline recommendations for the use of LMWH following birth.

The postpartum uterine ultrasonographic scale in assessment of uterine involution after cesarean section in treated thrombophilia pregnant patients at term

Background

Pregnancy is a prothrombotic condition which can be abnormally exaggerated in women with thrombophilia.

Methods

In a prospective study, patients who delivered at term, by cesarean section, between 1 October 2017 and 1 December 2021, who already had a diagnosis of thrombophilia before coming to our hospital, were included in the study group (n = 80). A similar number of nonthrombophilia patients (n = 80) without any history of thrombotic events, age‐ and para‐matched with the study group, were included in the control group. The postpartum uterine ultrasonographic scale (PUUS) values, in the first 24–48 h, were correlated with the patients' data.

Results

The P‐LCR (platelet large cell ratio), was significantly higher in the treated thrombophilia group (p = 0.042). There was no correlation between PUUS and complete blood count values, coagulation factors, maternal characteristics, or fetal outcomes, except for postpartum neutrophils (p = 0.047) and postpartum platelet count (p = 0.046).

Conclusions

Postpartum uterine involution was not significantly different, after cesarean section, between treated thrombophilia patients and nonthrombophilia patients. Involution correlated only with postpartum neutrophils and postpartum platelet count.

Management of anticoagulation in pregnant women with venous thromboembolism: An international survey of clinical practice

INTRODUCTION

Venous thromboembolism (VTE) is an important cause of maternal morbidity and mortality. During pregnancy, VTE is treated with low-molecular-weight-heparin (LMWH). Studies assessing the optimal duration and peripartum management of therapeutic anticoagulation are lacking. This survey aimed to assess clinician practices for the management of anticoagulation in pregnant women with acute VTE.

METHODS

An electronic survey consisting of clinical scenarios addressing anticoagulation management for VTE in pregnancy was created. The target sample was clinicians likely to be involved in the management of pregnant women with acute VTE. The survey completion rate and proportion of individuals selecting a response were determined.

RESULTS

96 respondents completed the survey including general internists (56.3%), hematologists (21.9%), and obstetricians (6.3%). In the management of a VTE in first or second trimester, most respondents preferred therapeutic LMWH until 6 weeks postpartum. In the first and second trimester, 48.0% and 37.5% of respondents, respectively, opted to reduce the dose of anticoagulation after 3 or 6 months. 29.2% of physicians opted for bridging with intravenous heparin around delivery when treating a VTE in the third trimester. 73.0% perceived an increased risk of clinically relevant non-major bleeding associated with the use of therapeutic anticoagulation in the peripartum and postpartum periods.

CONCLUSIONS

The survey highlights a wide variability of practice in the management of therapeutic anticoagulation in pregnancy. Larger scale studies with relevant clinical outcomes including thrombosis and bleeding risks are needed to inform clinical practice.