Venous thromboembolism incidence among patients recommended for pharmacologic thromboembolism prophylaxis after cesarean delivery in selected guidelines

Abstract

Background Multiple guidelines regarding risk stratification for venous thromboembolism (VTE) incidence following cesarean delivery have been promulgated. Objective To estimate the percentage of cesarean delivery patients for which pharmacologic VTE would be recommended and subsequent incidence of VTE, based on several guidelines. Patients/Methods This retrospective cohort study used data from the Nationwide Readmissions Database from October 2015 through December 2017. Diagnosis and procedure codes were used to identify patients undergoing cesarean delivery, incidence of VTE, and risk factors used to stratify risk in the existing guidelines. Time‐to‐event analysis was used to analyze data, stratified by risk categorization in 2011 American College of Obstetricians and Gynecologists (ACOG), 2012 American College of Chest Physicians (ACCP), 2015 Royal College of Obstetricians and Gynaecologists (RCOG), and 2018 American Society of Hematology (ASH) guidelines. Results/Conclusions In a cohort of 1 235 149 cesarean deliveries, VTE incidence was 2.1 per 1000 deliveries at 330 days following delivery (95% confidence interval: 2.0–2.2). Proportions of patients that would be recommended for pharmacologic prophylaxis ranged from 0.2% in 2018 ASH guidelines to 73.4% in 2015 RCOG criteria. Among groups considered at elevated risk for VTE for which pharmacologic prophylaxis would be recommended, VTE incidence varied from 35.2 per 1000 deliveries based on 2018 ASH criteria to 2.5 per 1000 in 2015 RCOG criteria. In a large cohort of cesarean deliveries in the United States, application of different risk stratification guidelines identified widely different proportions at risk of VTE following delivery, with implications for being categorized as having elevated risk.

Trends in Venous Thromboembolism and Associated Risk Factors During Delivery Hospitalizations From 2000 to 2018

“…13 For these analyses, ICD-9-CM codes were translated to ICD-10-CM codes using the publicly available General Equivalence Mappings provided by the Centers for Medicare & Medicaid Services and National Center for Health Statistics, and by reviewing prior research. 9,14 This study had three objectives. The first objective was to determine temporal trends in rate of VTE during delivery hospitalizations.…”

“…Additionally, there are limited data on obstetric VTE trends after 2014. 9 Given that addressing knowledge gaps related to VTE risk may be of clinical significance, the objectives of this study were to characterize temporal trends in VTE during delivery hospitalizations, temporal trends in common obstetric and medical risk factors for VTE, and the relationship between risk factors and likelihood of VTE events.…”

Prevention and management of venous thromboembolism in pregnancy: cutting through the practice variation

“…13 In a large US database study of over 1.2 mil lion cesar ean deliv er ies, patients who were iden ti fied as "ele vated risk" by the 2018 ASH guide lines had an actual VTE inci dence of 20.0 (14.9-25.7) per 1000 cesar ean deliv er ies (2% risk) at 6 weeks post par tum, whereas other clin i cal prac tice guide lines' "high-risk" categories had lower actual VTE inci dences (Table 2). 22 In con trast, in a sin gle-cen ter study, the highest cal cu lated VTE risk was approx i ma tely 0.5% using a risk score derived by Sultan et al 31 , which is lower than the VTE risk threshold cutoff suggested by the ASH guidelines. 23 There have been preg nancy and post par tum VTE risk scores derived and exter nally val i dated from large reg is try data bases, but these scores have yet to be stud ied pro spec tively or incorpo rated into guide lines.…”

Preventing Postpartum Venous Thromboembolism in 2022: A Narrative Review

“…Currently, guidelines suggest to risk stratify using empiric schemes of levels or combination of risk factors in several categories: no thromboprophylaxis or mechanical thromboprophylaxis only, short-term pharmacologic thromboprophylaxis (days) and 6-weeks of pharmacologic thromboprophylaxis. Importantly, such guidelines (ACOG ( 26 ), RCOG ( 27 ), ASH ( 24 )), which are detailed elsewhere, diverge dramatically in the proportion of women with advised thromboprophylaxis, between 7 and 40% for all deliveries ( 28 ) and 0.2–73% for cesarean deliveries ( 29 ). Logically, a higher prevalence of use of thromboprophylaxis is associated with lower risks among those with thromboprophylaxis, and greater numbers needed to treat to prevent 1 VTE.…”