1 in 1000
The pregnant woman’s odds of developing a blood clot. These odds rise to 3 in 1000
after a C-section delivery.
1 in 1000 pregnant women will have a blood clot
Contributor
Jackie Haigney
Essential Insights contributor, healthcare writer
Featured expert
William Nadeau, MS, RD
Medical Affairs Director, Cardinal Health
Reducing the risk of a blood clot, as a new mother
New mothers want to do everything they can to stay healthy ― for them and for their baby.
Although it is not always realized, awareness of the potential for blood clots is important, both during pregnancy and after delivery. A pregnant woman’s odds of developing a blood clot are 1 in 1000. And those odds rise to 3 in 1000 after a C-section delivery.
Understanding the increased risk of VTE
Pregnancy and the postpartum period are well-established risk factors for venous thromboembolism (VTE), a disease that includes pulmonary embolism (PE) and deep venous thrombosis (DVT). In fact, a pregnant woman’s VTE risk is four to five times greater than that of a non-pregnant woman.
That’s why pregnant women – and their healthcare providers – need to stay aware of the risk for blood clotting both during pregnancy and after delivery. The more informed a pregnant patient is, the more she will be able to participate in making good decisions to protect her health.
The rising rate of VTE and its consequences
More than doubled
The maternal death rate in the United States has been rising. In fact, it has more than doubled
from 1987 to 2015.
The statistics are sobering. VTE is one of the leading causes of maternal mortality. And the maternal death rate in the United States has more than doubled from 1987 to 2015.
The increased number of C-section deliveries and higher maternal age may have contributed to this trend. The good news is that there are options to help prevent VTE ― and change the statistics.
Recommendations for preventing VTE
To help reverse the rise in VTE incidence rates, several major health organizations have published treatment guidelines.
The American College of Obstetricians and Gynecologists (ACOG) guidelines recommend the use of intermittent pneumatic compression (IPC) devices before C-section for pregnant women who are not already receiving VTE prevention measures.
ACOG also recommends the continued use of IPC until the patient is ambulatory and anticoagulation therapy is restarted, when anticoagulation therapy is needed after delivery.
For pregnant women with additional risk factors, dual modalities are recommended. Therapeutic anticoagulation is recommended for women with acute thromboembolism during the current pregnancy or those at high risk of VTE, such as women with mechanical heart valves.
The guidelines identify risk factors to watch for including history of VTE, obesity, hypertension and smoking.
The Physician-Patient Alliance for Health & Safety (PPAHS) is an advocacy group dedicated to improving patient health and safety. They recommend to:
- Use IPC for moderate/high/highest risk patients for vaginal and C-section delivery.
- Consider at-home IPC for patients on bed rest or with associated risk.
The Saint Louis University School of Medicine conducted a study comparing the compliance for two IPC devices, foot cuffs and leg sleeves, in the prevention of VTE in antepartum (prior to childbirth) patients which showed poor compliance to wear time for IPC devices. The study was presented at the ACOG 61st Annual Clinical Meeting (May, 2013).
Working with a group of thought leaders in obstetrics to address the issue of VTE in pregnancy, Thinh P. Nguyen, MD, from Saint Louis University, concludes, “the study demonstrates the need for better awareness and education about how VTE can be prevented, managed and treated during pregnancy.”
Steps recommended by PPAHS to prevent VTE in maternal patients
VTE prophylaxis timeline
2. Prophylaxis regimen
Antepartum
- If low to medium risk
Pharmacological prophylaxis* not recommended unless indicated
Medium risk - mechanical prophylaxis† prescribed - If high to highest risk
- Pharmacological prophylaxis*
- High risk - ordered if VTE unprovoked and/or thrombophilia and/or hormonally provoked
- Highest risk - ordered
- Mechanical prophylaxis† initiated
- Pharmacological prophylaxis*
Postpartum
- If low to medium risk
- Early ambulation as prescribed by healthcare provider
- Pharmacological prophylaxis* not recommended unless indicated
- Medium risk – pharmacological prophylaxis* considered
- Mechanical prophylaxis† initiated
- If high to highest risk
- Pharmacological prophylaxis* (not administered until 12 hours after vaginal delivery/epidural removal or 24 hours after C-section delivery)
- Mechanical prophylaxis† initiated
3. Patient reassessment
Repeat assessment if patient hospitalized longer than 24 hours, before surgery or with any significant change in patient condition
- Assess patient for VTE risk and document (see step 1)
- Pharmacological prophylaxis*
- Continued as prescribed
- Not ordered, why?
- Mechanical prophylaxis†
- Not prescribed
- If prescribed, patient provided with information on proper use and wearing
- Initiate discharge planning
- Discuss with patient/family
- Anticipate discharge date determined
- Evaluate patient for home use of:
- Intermittent pneumatic compression (IPC), or
- Venous foot pump (VFP), or
- No IPC/VFP
- If evaluated for IPC/VFP, initiate availability on discharge
4. Patient discharged
- Included in discharge instructions
- HCP contact information
- DVT patient education - signs and symptoms
- Evaluate patient for IPC/VFP home use
- Discharge instructions reviewed with and received by patient
- Patient understands DVT/PE risk factors and how to prevent postpartum DVT or PE
- Follow-up appointment made if immobility or bed rest is required
- Order completed
- Identification of IPC/VFP
- Length of IPC therapy determined
- DME notified of start date of IPC therapy
- Review importance of maintaining use at home until discontinued by doctor
- Removed for ambulation and skin inspections (every 8h)
- Worn at least 18-20 hours per day for immobile patients
Prevention benefits of IPC
The healthcare community agrees that the key to preventing VTE in higher risk mothers ― before and after delivery ― is to implement protocols for use of:
- IPC
- Anticoagulants
In a decision analysis model, four strategies for managing patients after C-section delivery were compared. As the graph here shows, using IPC after C-section delivery is the strategy that results in the lowest number of adverse events.
Rate of event in a theoretic cohort of 1,000,000 women
Bridging the gap in anticoagulation protection
Although the risk for VTE during pregnancy and postpartum is well known, there is little data from large trials on the optimal use of anticoagulants for prevention.
The ACOG acknowledges that routine anticoagulation therapy is not warranted for all pregnant and postpartum women. In fact, they recommend that the risks of bleeding be assessed before starting a woman on anticoagulation therapy with low molecular weight heparin (LMWH) and unfractionated heparin (UH).
As an effective option for prophylaxis, both the American College of Obstetricians and Gynecologists (ACOG) and the Royal College of Obstetricians & Gynaecologists (RCOG) recommend the use of IPC to help prevent VTE.
Footnotes:
[Adapted from Ob/Gyn VTE Safety Recommendations for the Prevention of VTE in Maternal Patients (Applies to C-section and Vaginal Delivery)]
*Pharmacological prophylaxis:
- Prophylactic low-molecular weight heparin (LMWH); or
- If LMWH unavailable, unfractionated heparin (UFH) 5000 IU BID
- If not ordered, why?
†Mechanical prophylaxis:
- Graduated compression stockings, and either:
- Intermittent pneumatic compression, or
- Venous foot pump
- On patient
- Properly worn
- Patient provided with information on proper use and wearing