Original Investigation
June 27, 2024
A More Selective vs a Standard Risk-Stratified, Heparin-Based, Obstetric Thromboprophylaxis Protocol
Macie L. Champion, Christina T. Blanchard, Michelle Y. Lu, et al
JAMA. 2024;332(4):310-317. doi:10.1001/jama.2024.8684
Question Among patients with increased risk of postpartum venous thromboembolism, does a more selective protocol for initiating postpartum enoxaparin, compared with a standard risk-stratified protocol, decrease wound complications without increasing patient risk of venous thromboembolism?
Findings In this retrospective observational study, a more selective protocol for chemoprophylaxis resulted in a decrease in heparin (enoxaparin) administration (16% vs 8%). The selective protocol for postpartum enoxaparin was associated with a decrease in wound hematoma (0.7% vs 0.3% in the selective protocol group; adjusted odds ratio, 0.38; 95% CI, 0.21-0.67) without evidence of increase in venous thromboembolism (0.1% vs 0.1% in the selective protocol group; adjusted odds ratio, 0.40; 95% CI, 0.12-1.36).
Meaning A more selective protocol for postpartum enoxaparin was associated with decreased rates of wound hematomas without evidence of increased rates of postpartum thromboembolic events.
Abstract
Importance In 2016, our institution adopted a pregnancy-related venous thromboembolism (VTE) prophylaxis protocol based on American College of Obstetricians and Gynecologists guidelines that recommended postpartum heparin-based chemoprophylaxis (enoxaparin) based on a risk-stratified algorithm. In response to increased wound hematomas without significant reduction in VTE using this protocol, a more selective risk-stratified approach was adopted in 2021.
Objective To evaluate outcomes of the more selective risk-stratified approach to heparin-based obstetric thromboprophylaxis (enoxaparin) protocol.
Design, Setting, and Participants Retrospective observational study of 17 489 patients who delivered at a single tertiary care center in the southeast US between January 1, 2016, and December 31, 2018 (original protocol), and between December 1, 2021, and May 31, 2023 (more selective protocol). Patients receiving outpatient anticoagulation for active VTE or high VTE risk during pregnancy were excluded.
Exposure Standard risk-stratified and more selective postpartum VTE chemoprophylaxis protocols.
Main Outcomes and Measures The primary outcome was clinical diagnosis of wound hematoma up to 6 weeks pos tpartum. The secondary outcome was new diagnosis of VTE up to 6 weeks post partum. We compared baseline characteristics and outcomes between groups and estimated adjusted odds ratios with 95% CIs of primary and secondary outcomes using the original protocol group as reference.
Results Of 17 489 patients included in the analysis, 12 430 (71%) were in the original protocol group and 5029 (29%) were in the more selective group. Rates of chemoprophylaxis decreased from 16% (original protocol) to 8% (more selective protocol). Patients in the more selective group were more likely to be older, be married, and have obesity or other comorbidities (hypertension, diabetes, cardiac disease). Compared with the original protocol, the more selective protocol was associated with a decrease in any wound hematoma (0.7% vs 0.3%; adjusted odds ratio [aOR], 0.38; 95% CI, 0.21-0.67), specifically due to a lower rate of superficial wound hematomas (0.6% vs 0.3%; aOR, 0.43; 95% CI, 0.24-0.75). There was no significant increase in VTE or individual types of VTE (0.1% vs 0.1%; aOR, 0.40; 95% CI, 0.12-1.36).
Conclusions and Relevance A more selective risk-stratified approach to an enoxaparin thromboprophylaxis protocol for VTE was associated with decreased rates of wound hematomas without increased rates of postpartum VTE.
