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Venous thromboembolism and adverse outcomes in highest thromboembolism risk patients compared with those at lower risk

  • Margaret R. Page
    Correspondence
    Corresponding author: Margaret R. Page, MD.
    Affiliations
    Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Lu, Casey, and Tita, Mr Kim, and Drs Szychowski and Subramaniam)

    Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Casey and Tita, Mr Kim, and Drs Szychowski and Subramaniam)
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  • Gabriella D. Cozzi
    Affiliations
    Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Lu, Casey, and Tita, Mr Kim, and Drs Szychowski and Subramaniam)

    Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Casey and Tita, Mr Kim, and Drs Szychowski and Subramaniam)
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  • Christina T. Blanchard
    Affiliations
    Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Lu, Casey, and Tita, Mr Kim, and Drs Szychowski and Subramaniam)

    Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Casey and Tita, Mr Kim, and Drs Szychowski and Subramaniam)
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  • Michelle Y. Lu
    Affiliations
    Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Lu, Casey, and Tita, Mr Kim, and Drs Szychowski and Subramaniam)

    Wildflower Obstetrics and Gynecology, Austin, TX (Dr Lu)
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  • Elizabeth B. Ausbeck
    Affiliations
    Novant Health Maternal-Fetal Medicine, Charlotte, NC (Dr Ausbeck)
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  • Brian M. Casey
    Affiliations
    Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Lu, Casey, and Tita, Mr Kim, and Drs Szychowski and Subramaniam)

    Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Casey and Tita, Mr Kim, and Drs Szychowski and Subramaniam)
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  • Alan T. Tita
    Affiliations
    Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Lu, Casey, and Tita, Mr Kim, and Drs Szychowski and Subramaniam)

    Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Casey and Tita, Mr Kim, and Drs Szychowski and Subramaniam)
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  • Dhong-Jin Kim
    Affiliations
    Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Lu, Casey, and Tita, Mr Kim, and Drs Szychowski and Subramaniam)

    Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Casey and Tita, Mr Kim, and Drs Szychowski and Subramaniam)
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  • Jeff M. Szychowski
    Affiliations
    Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Lu, Casey, and Tita, Mr Kim, and Drs Szychowski and Subramaniam)

    Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Casey and Tita, Mr Kim, and Drs Szychowski and Subramaniam)

    Department of Biostatistics, The University of Alabama at Birmingham, Birmingham AL (Dr Szychowski)
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  • Akila Subramaniam
    Affiliations
    Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Lu, Casey, and Tita, Mr Kim, and Drs Szychowski and Subramaniam)

    Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Casey and Tita, Mr Kim, and Drs Szychowski and Subramaniam)
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      BACKGROUND

      A risk-based institutional protocol for inpatient heparin-based venous thromboembolism prophylaxis in a general obstetrical population previously demonstrated a greater than 2-fold increase in wound hematomas with no change in the frequency of thromboembolism.

      OBJECTIVE

      We sought to compare the rates of thromboembolism and bleeding outcomes in patients at the highest risk for thromboembolism (eg, those with a history of thromboembolism or thrombophilia who require anticoagulation prophylaxis or therapy throughout pregnancy) than low-risk patients.

      STUDY DESIGN

      We performed a retrospective cohort study of all deliveries >20 weeks at a single center from 2013–2018. Patients were categorized as high-risk (received outpatient heparin-based prophylaxis or treatment) or low-risk (no outpatient anticoagulation). The primary outcome was newly diagnosed postpartum thromboembolism; the main secondary outcome was wound/perineal hematoma. The outcomes were compared between the high- and low-risk cohorts. Adjusted odds ratios (with 95% confidence intervals) were calculated with the low-risk group as reference.

      RESULTS

      Of 24,303 total deliveries, 395 (1.7%) were high-risk and 23,905 (98.3%) were low-risk. Among the low-risk patients, 8.6% received anticoagulation prophylaxis in accordance with our risk-based inpatient thromboembolism prophylaxis protocol. High-risk patients were more likely to be older and have a higher body mass index, earlier delivery gestational age, medical comorbidities, and pregnancy complications, eg, preeclampsia. Despite outpatient antepartum anticoagulation, high-risk patients had an 11-fold increased risk of thromboembolism (adjusted odds ratio, 11.1 [4.7–26.2]) than low-risk patients. High-risk patients also had significantly more wound/perineal hematomas (adjusted odds ratio, 4.8 [2.7–8.4]), overall wound complications (adjusted odds ratio, 3.0 [2.0–4.4]), blood transfusions, intensive care unit admissions, maternal deaths, and longer maternal lengths of stay.

      Conclusion

      Patients at the highest risk of obstetrical thromboembolism had an 11-fold increased risk of thromboembolism with a more moderate increase (∼5-fold) in postpartum wound and bleeding complications than low-risk patients. This more favorable risk or benefit profile supports current anticoagulation recommendations in high-risk patients.

      Key words

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