Postpartum thromboprophylaxis in a multireligious cohort: a retrospective review of indications and uptake

Abstract

Strategies to prevent mortality from obstetric venous thromboembolism begin with identification, risk stratification and subsequently, implementation of prophylactic measures. We sought to identify the burden of pharmacologic thromboprophylaxis in postpartum women, including the main clinical indications and its uptake in a multireligious population, with Islam as the official religion. A total of 2514 deliveries between 1st January to 31st December 2016, across three centres in Malaysia were reviewed retrospectively from hospital-based registries. 770 (30.62%) patients fulfilled the criteria for thromboprophylaxis based on the revised 2015 criteria proposed by the Royal College of Obstetricians and Gynaecologists. A combination of age, parity, BMI, caesarean section and preterm births were the main indications. One out of the five patients who delivered vaginally required thromboprophylaxis. In our setting with a sizable Muslim population, low molecular weight heparin was the thromboprophylaxis of choice in more than two-third of the patients. The information obtained from this study allows better local resource planning. Impact statement What is already known on this subject: Risk factors for venous thromboembolism in pregnancy and puerperium are largely drawn from registries due to the rarity of the index event. Up to 7% of women require antenatal thromboprophylaxis based on the criteria proposed by the Royal College of Obstetrician and Gynaecologists in 2009. What do the results of this study add: Using the RCOG guideline revised in 2015, a significant proportion of women delivering vaginally would require postnatal thromboprophylaxis based on age, parity and BMI. When either age or parity, both with relatively low odds ratio for thrombosis were omitted, a substantial proportion of women would not achieve the threshold for prophylaxis. Despite a sizable Muslim population in the country, the uptake of low molecular weight heparin was relatively high. What are the implications of these findings for clinical practice and/or future research: Cost-benefit studies should consider the adjusted odds ratio of individual indications on a VTE event. While uptake and acceptability is high, prospective studies on medication adherence is equally pertinent.

Application of the RCOG Risk Assessment Model for Evaluating Postpartum Venous Thromboembolism in Chinese Women: A Case-Control Study

“…During its application in other Asian countries, it was found that the RCOG RAM might lead to the overuse of anticoagulant drugs in women who are less likely to develop postpartum VTE. A retrospective study in Malaysia suggested that 30.62% of postpartum women without VTE met the criteria for thromboprophylaxis [ 18 ]. Our study reached a similar conclusion.…”

Impact of Pregnancy-Related Venous Thromboembolism on Quality of Patients’ Lives

“…In a setting with a sizable Muslim population, low molecular weight heparin was the thromboprophylaxis of choice in more than two-third of the patients. 34 The extended hospitalization in our practice was mostly defensive medical practice and fear of litigations. This increased risk continues for up to 6 to 12 weeks postpartum.…”

Hospital Variation and Associated Organizational Factors of Pregnancy-Related Venous Thromboembolism in China

“… 1 , 2 In pregnant women, venous thromboembolism (VTE) presents as deep vein thrombosis (DVT) or pulmonary embolism (PE). 3 , 4 In recent decades, VTE has become a leading cause of sudden death, which occurs in every 1600 pregnancies, and PE accounted for 9% of overall maternal deaths. 5 , 6 It is well recognized that pregnancy increases the risk of thromboembolism under conditions of hypercoagulability, decreased mobility, and compression of the inferior vena cava and pelvic veins.…”

“… 5 , 6 It is well recognized that pregnancy increases the risk of thromboembolism under conditions of hypercoagulability, decreased mobility, and compression of the inferior vena cava and pelvic veins. 3 , 4 Therefore, there is an urgent need to recognize risk factors of pregnancy-related VTE.…”