Do these recommendations go too far?
The proposed NPMS VTE bundle has been criticized as non-evidence—based and too costly. Sibai and Rouse have leveled 4 major critiques.11 The first is that the Padua and Caprini scoring systems advocated for use in pregnant patients were derived from low-quality evidence collected in generally older patients, many of whom had cancer, respiratory and cardiac failure, and other serious comorbidities rarely found in pregnant populations. Second, the antepartum NPMS thromboprophylaxis recommendations fly in the face of a recent Cochrane review that concluded insufficient evidence existed to justify such a policy. Indeed, this report concluded there was also insufficient evidence to justify post-cesarean prophylaxis at this time.12 Third, Sibai and Rouse criticize the NPMS authors for not stating how long thromboprophylaxis should be continued after vaginal delivery (2 days or 6 weeks?).
Finally, they note that the RCOG criteria for thromboprophylaxis after cesarean delivery would apply to half of US cesarean delivery patients (1.2 million a year) and cost up to $52 million for a 4-day course and $130 million for a 10-day course, just for the drugs. Universal application would double these costs. Moreover, additional costs would accrue from the hemorrhagic complications of such therapy. Sibai and Rouse also point out that the NPMS authors’ concern about patient and hospital staff non-adherence with pneumatic compression device use flies in the face of the aforementioned findings by Clark and associates5 and they advocate increased use of this modality as an alternative to the proposed NPMS VTE bundle.
Our rising national maternal mortality rates should concern us all. Clearly, intensive study must be brought to bear on all such causes, especially on the rapid rise in cardiovascular-related deaths, which also have far broader public health implications (see my editorial “Ob/gyns should join the fight against quiet killer,” ContemporaryOBGYN.net/quiet-killer). Moreover, although fatal PEs represent a substantially lower proportion of total maternal deaths compared with 2 decades ago, as noted previously, virtually all deaths from PE are at least theoretically preventable. Thus, the question at hand is: Just how far are we willing to go in preventing pregnancy-related VTE both in terms of dollars spent and complications accepted per life saved?
I believe ACOG should carefully consider the NPMS recommendations and modestly liberalize its indications for pharmacological thromboprophylaxis. In the interim, we should all work hard to ensure that at-risk patients are adherent with pneumatic compression devices and that nurses and physicians are equally vigilant in ensuring such adherence. I suggest joining your postpartum charge nurse and rounding on all your facilities’ post-cesarean delivery patients. You may be astounded by how few of these women actually have pneumatic compression devices applied to their legs!
1. Centers for Disease Control and Prevention. Pregnancy Mortality Surveillance System. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html.
2. Centers for Disease Control and Prevention. Pregnancy-Related Mortality Surveillance—United States, 1991–1999. Causes of pregnancy-related death, by outcome of pregnancy and pregnancy-related mortality ratios (PRMR), United States, 1991–1999. https://www.cdc.gov/mmwr/preview/mmwrhtml/ss5202a1.htm#tab3.
3. Ghaji N, Boulet SL, Tepper N, Hooper WC. Trends in venous thromboembolism among pregnancy-related hospitalizations, United States, 1994-2009. Am J Obstet Gynecol. 2013;209(5):433.e1-8.
4. James A; Committee on Practice Bulletins—Obstetrics Practice Bulletin No. 123: thromboembolism in pregnancy. Obstet Gynecol. 2011;118(3):718-729.
5. Clark SL, Christmas JT, Frye DR, Meyers JA, Perlin JB. Maternal mortality in the United States: predictability and the impact of protocols on fatal postcesarean pulmonary embolism and hypertension-related intracranial hemorrhage. Am J Obstet Gynecol. 2014;211(1):32.e1-9.
6. DÊ¼Alton ME, Main EK, Menard MK, Levy BS. The National Partnership for Maternal Safety. Obstet Gynecol. 2014;123(5):973-977.
7. DÊ¼Alton ME, Friedman AM, Smiley RM, Montgomery DM, Paidas MJ, DÊ¼Oria R, Frost JL, Hameed AB, Karsnitz D, Levy BS, Clark SL. National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism. Obstet Gynecol. 2016;128(4):688-698.
9. Bahl V, Hu HM, Henke PK, Wakefield TW, Campbell DA Jr, Caprini JA. A validation study of a retrospective venous thromboembolism risk scoring method. Ann Surg. 2010;251(2):344-350.
10. Barbar S, Noventa F, Rossetto V, et al. A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score. J Thromb Haemost. 2010;8(11):2450-2457.
11. Sibai BM, Rouse DJ. Pharmacologic thromboprophylaxis in obstetrics: broader use demands better data. Obstet Gynecol. 2016;128(4):681-684.
12. Bain E, Wilson A, Tooher R, Gates S, Davis LJ, Middleton P. Prophylaxis for venous thromboembolic disease in pregnancy and the early postnatal period. Cochrane Database Syst Rev. 2014;(2):CD001689.