Postpartum pharmacologic thromboprophylaxis and complications in a US cohort

Ann M. Bruno, Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, UT. Electronic address: ann.bruno@hsc.utah.edu.
Grecio J. Sandoval, George Washington University Biostatistics Center, Washington, DC.
Brenna L. Hughes, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
William A. Grobman, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL.
George R. Saade, Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX.
Tracy A. Manuck, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
Monica Longo, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD.
Torri D. Metz, Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, UT.
Hyagriv N. Simhan, Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, PA.
Dwight J. Rouse, Department of Obstetrics and Gynecology, Brown University, Providence, RI.
Hector Mendez-Figueroa, University of Texas Health Science Center at Houston, Children's Memorial Hermann Hospital, Houston, TX.
Cynthia Gyamfi-Bannerman, Department of Obstetrics and Gynecology, Columbia University, New York, NY.
Jennifer L. Bailit, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH.
Maged M. Costantine, Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH.
Harish M. Sehdev, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA.
Alan T. Tita, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL.

Document Type

Journal Article

Publication Date

2-8-2024

Journal

American journal of obstetrics and gynecology

DOI

10.1016/j.ajog.2023.11.013

Keywords

bleeding complications; heparin-based prophylaxis; postcesarean thromboprophylaxis; postpartum thromboembolism; rates of prophylaxis; wound complications

Abstract

BACKGROUND: Venous thromboembolism accounts for approximately 9% of pregnancy-related deaths in the United States. National guidelines recommend postpartum risk stratification and pharmacologic prophylaxis in at-risk individuals. Knowledge on modern rates of postpartum pharmacologic thromboprophylaxis and its associated risks is limited. OBJECTIVE: This study aimed to describe the rate of, and factors associated with, initiation of postpartum pharmacologic prophylaxis for venous thromboembolism, and to assess associated adverse outcomes. STUDY DESIGN: This was a secondary analysis of a multicenter cohort of individuals delivering on randomly selected days at 17 US hospitals (2019-2020). Medical records were reviewed by trained and certified personnel. Those with an antepartum diagnosis of venous thromboembolism, receiving antepartum anticoagulation, or known SARS-CoV-2 infection were excluded. The primary outcome was use of postpartum pharmacologic thromboprophylaxis. Secondary outcomes included bleeding complications, surgical site infection, hospital readmission, and venous thromboembolism through 6 weeks postpartum. The rate of thromboprophylaxis administration was assessed by mode of delivery, institution, and continuance to the outpatient setting. Multivariable regression models were developed using k-fold cross-validation with stepwise backward elimination to evaluate factors associated with thromboprophylaxis administration. Univariable and multivariable logistic models with propensity score covariate adjustment were performed to assess the association between thromboprophylaxis administration and adverse outcomes. RESULTS: Of 21,114 individuals in the analytical cohort, 11.9% (95% confidence interval, 11.4%-12.3%) received postpartum pharmacologic thromboprophylaxis; the frequency of receipt was 29.8% (95% confidence interval, 28.7%-30.9%) following cesarean and 3.5% (95% confidence interval, 3.2%-3.8%) following vaginal delivery. Institutional rates of prophylaxis varied from 0.21% to 34.8%. Most individuals (83.3%) received thromboprophylaxis only as inpatients. In adjusted analysis, cesarean delivery (adjusted odds ratio, 19.17; 95% confidence interval, 16.70-22.00), hysterectomy (adjusted odds ratio, 15.70; 95% confidence interval, 4.35-56.65), and obesity (adjusted odds ratio, 3.45; 95% confidence interval, 3.02-3.95) were the strongest factors associated with thromboprophylaxis administration. Thromboprophylaxis administration was not associated with surgical site infection (0.9% vs 0.6%; odds ratio, 1.48; 95% confidence interval, 0.80-2.74), bleeding complications (0.2% vs 0.1%; odds ratio, 2.60; 95% confidence interval, 0.99-6.80), or postpartum readmission (0.9% vs 0.3%; adjusted odds ratio, 1.38; 95% confidence interval, 0.68-2.81). The overall rate of venous thromboembolism was 0.06% (95% confidence interval, 0.03%-0.10%) and was higher in those receiving prophylaxis (0.2%) compared with those not receiving prophylaxis (0.04%). CONCLUSION: Approximately 1 in 10 patients received postpartum pharmacologic thromboprophylaxis in this US cohort. Rates of prophylaxis varied widely by institution. Cesarean delivery, hysterectomy, and obesity were predominant factors associated with postpartum thromboprophylaxis administration.

Department

Biostatistics and Bioinformatics

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