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STUDENT IJMR
Year : 2020  |  Volume : 152  |  Issue : 5  |  Page : 523-526

Risk stratification for venous thrombosis in post-partum women in a tertiary care setup in south India


1 Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
2 Department of Obstetrics & Gynaecology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
3 Department of Preventive & Social Medicine, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India

Date of Submission20-Aug-2018
Date of Web Publication8-Mar-2021

Correspondence Address:
Dr. Gowri Dorairajan
Department of Obstetrics & Gynecology, Women & Child Block, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmr.IJMR_1564_18

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   Abstract 

Background & objectives: The Royal College of Obstetricians and Gynaecologists (RCOG) guidelines for thromboprophylaxis among post-partum women are recommended across Asia. This study was aimed to find the proportion of post-partum women eligible for thromboprophylaxis based on the RCOG guidelines and how many actually received it in a tertiary care health facility in south India.
Methods: This cross-sectional study was carried out on 1652 consecutive women who delivered in the setup of tertiary care. Risk stratification for venous thrombosis was done as per the RCOG guidelines. The number of women who received thromboprophylaxis was also noted.
Results: Among the 1652 women studied, three [0.18%; 95% confidence interval (CI): 0.06-0.53] were in the high-risk, 598 (36.2%; 95% CI: 33.9-38.6) in the intermediate and 254 (15.4%; 95% CI: 13.7-17.2) in the low-risk category for thrombosis. All the three women in the high-risk and only two women in the intermediate-risk category actually received thromboprophylaxis with heparin.
Interpretation & conclusions: It was seen that the number of women needing prophylaxis in our setup, as per the RCOG guidelines, was as high as 601 (36.4%), but only five (0.8%) received it.

Keywords: Post-partum thrombosis - thromboprophylaxis - thrombosis risk - venous thrombosis


How to cite this article:
Sahoo DR, Dorairajan G, Palanivel C. Risk stratification for venous thrombosis in post-partum women in a tertiary care setup in south India. Indian J Med Res 2020;152:523-6

How to cite this URL:
Sahoo DR, Dorairajan G, Palanivel C. Risk stratification for venous thrombosis in post-partum women in a tertiary care setup in south India. Indian J Med Res [serial online] 2020 [cited 2021 Sep 25];152:523-6. Available from: https://www.ijmr.org.in/text.asp?2020/152/5/523/310878

The Royal College of Obstetricians and Gynaecologists (RCOG) has laid down criteria to stratify post-partum women into high, intermediate and low risks of thromboembolism[1]. Thromboprophylaxis is recommended for all post-partum women falling into high- and intermediate-risk categories. The occurrence of thromboembolism is two to five times higher in the African-Americans and European countries. The risk has been considered lowest in the Asian population[2],[3]. However, in a recent study from India, the authors observed a hospital incidence of 19/10,000 of venous thromboembolism (VTE) with maximum incidence in 40 to 60 age group and half of the cases had an underlying provocative factor[4].

This study was undertaken to calculate the proportion of post-partum women, who would be eligible for anticoagulation, based on the RCOG guidelines, and how many were actually administered anticoagulants in a tertiary care health facility in south India.


   Material & Methods Top


This was a cross-sectional study carried out in the population of post-partum women aged 18-45 yr who delivered in the labour wards of the department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER) Puducherry, India, during April and May 2017, after obtaining written informed consent. The study was approved by the Institutional Ethics Committee. Women delivering before 28 wk were excluded from the study. With the frequency of the highest risk factor for thrombosis of acquired thrombophilia being one per cent[5] and an alpha error of five per cent, absolute precision of 0.5 per cent and non-response rate of 10 per cent, the sample size was calculated to be 1650. With the proportion being very low (1%), we took absolute precision of 0.5 per cent.

After collection of these data about risk factors, the proportion of women falling into different risk categories (no, low, intermediate and high risk) based on the RCOG guidelines criteria[1] [Table 1] was calculated. The proportion of women eligible for thromboprophylaxis (high and intermediate risk) and those who actually received was also calculated.
Table 1: Risk stratification criteria for venous thrombosis for post-partum women

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All the women in the study group were followed up only till discharge from the hospital (on an average of four days) for the development of any clinical thromboembolism. Data analysis was done in EpiData analysis version V2.2.2.186 (EpiData Association, Odense, Denmark).


   Results & Discussion Top


There were 25 (1.5%) teenage pregnancies (18-19 yr). Only 2.5 per cent (n=42) were more than 35 yr of age. [Table 2] gives the various demographic characteristics of the study group. Nearly half of the study population (n=797; 48%) had no risk, three (0.2%) had high risk, 598 (36.2%) had intermediate and 254 (15.4%) had low risk for thrombosis based on the RCOG guidelines.
Table 2: Baseline characteristics of the study population (n=1652)

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Among the 1652 women, three women (one with thrombophilia and family history of thrombosis and two who had undergone mitral valve replacement for rheumatic heart disease) had high risk of thrombosis, and no woman had previous VTE. Of the 598 women with intermediate risk, 361 underwent emergency caesarean section. Twenty nine women stayed beyond three days due to systemic infections (including hepatitis B antigen positivity, dengue fever, urinary tract, minor and major respiratory tract and wound infection). Only two women were readmitted for wound infection requiring antibiotics and dressings. Two hundred and one women had two or more low risk factors which were recurring [pre-term labour (n=101, 50.2%), multiparity (n=72, 35.8%) and BMI in the range of 30-40 kg/m[2] (n=64, 31.8%)]. Of the 601 women eligible, only five actually received anticoagulation. This included all three of the high risk and only two from the intermediate-risk group (one with SLE and one with nephrotic syndrome). None of the 1652 women developed clinically obvious venous thrombosis during their hospital stay.

Venous thrombosis has been found to complicate one or two per 1000 pregnancies. The risk is higher in post-partum period varying from 0.5 to 3 per cent[6],[7],[8].

A Cochrane systematic review on thromboprophylaxis in pregnancy and the early post-natal period examined 16 randomized trials involving 2592 women. Nine trials were for post-partum prophylaxis. The authors concluded that the available evidence was insufficient to make firm recommendations for prophylaxis[9]. There are several guidelines available for prophylaxis for venous thrombosis in post-partum women[10],[11],[12],[13],[14],[15],[16]. The updated Asian guidelines continue to recommend the RCOG guidelines for post-partum prophylaxis[17]. In a recent critical appraisal of these guidelines, the authors brought about the controversy in the duration and type of anticoagulation and need after caesarean section. They recommended efforts towards population-specific high-quality evidence before formulation of guidelines[18].

In a study conducted in Western India, the authors[19] found the incidence of VTE in pregnancy as 0.1 per cent and thrombophilia was identified as an important underlying factor in most of these cases. The incidence of VTE was found to be 7.5/10,000 in Japan[20].

To conclude, it was found that by applying the RCOG guidelines, thromboprophylaxis was indicated for 36.4 per cent of post-partum women, but only 0.5 per cent of them actually received it.

Acknowledgment: This study was carried out under the GJSTRAUS scheme of JIPMER undergraduate research (GJSTRAUS_2016-17/09).

Financial support & sponsorship: None.

Conflicts of Interest: None.

 
   References Top

1.
Royal College of Obstetricians and Gynaecologists. Reducing the risk of thrombosis and embolism during pregnancy and the puerperium. Green-top guideline No. 37a. London, UK: Royal College of Obstetricians and Gynaecologists; 2015. Available from: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-37a.pdf, accessed on May 10, 2019.  Back to cited text no. 1
    
2.
Zakai NA, McClure LA. Racial differences in venous thromboembolism. J Thromb Haemost 2011; 9 : 1877-82.  Back to cited text no. 2
    
3.
White RH, Keenan CR. Effects of race and ethnicity on the incidence of venous thromboembolism. Thromb Res 2009; 123 (Suppl 4) : S11-7.  Back to cited text no. 3
    
4.
Pawar P, Ayyappan MK, Jagan J, Rajendra N, Mathur K, Raju R. Analysis of patients with venous thromboembolism in a multi-specialty tertiary hospital in South India. Indian J Vasc Endovasc Surg 2020; 7 : 29-33.  Back to cited text no. 4
    
5.
Varre H, Badveli M, Bammidi S, Mudragada US, Gupta PC, Atturu G. Prevalence of venous thromboembolism risk factors in pregnant women. Indian J Vasc Endovasc Surg 2020; 7 : 225-6.  Back to cited text no. 5
    
6.
Devis P, Knuttinen MG. Deep venous thrombosis in pregnancy: Incidence, pathogenesis and endovascular management. Cardiovasc Diagn Ther 2017; 7 : S309-19.  Back to cited text no. 6
    
7.
Meng K, Hu X, Peng X, Zhang Z. Incidence of venous thromboembolism during pregnancy and the puerperium: A systematic review and meta-analysis. J Matern Fetal Neonatal Med 2015; 28 : 245-53.  Back to cited text no. 7
    
8.
Sultan AA, West J, Grainge MJ, Riley RD, Tata LJ, Stephansson O, et al. Development and validation of risk prediction model for venous thromboembolism in postpartum women: Multinational cohort study. BMJ 2016; 355 : i6253.  Back to cited text no. 8
    
9.
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; 11 : CD001689.   Back to cited text no. 9
    
10.
James A, Committee on Practice Bulletins-Obstetrics. Practice bulletin no. 123: Thromboembolism in pregnancy. Obstet Gynecol 2011; 118 : 718-29.  Back to cited text no. 10
    
11.
Committee on Practice Bulletins-Obstetrics, American College of Obstetricians and Gynecologists. Practice Bulletin No. 132: Antiphospholipid syndrome. Obstet Gynecol 2012; 120 : 1514-21.   Back to cited text no. 11
    
12.
Chan WS, Rey E, Kent NE; VTE in Pregnancy Guideline Working Group, Chan WS, Kent NE, et al. Venous thromboembolism and antithrombotic therapy in pregnancy. J Obstet Gynaecol Can 2014; 36 : 527-53.  Back to cited text no. 12
    
13.
McLintock C, Brighton T, Chunilal S, Dekker G, McDonnell N, McRae S, et al. Recommendations for the diagnosis and treatment of deep venous thrombosis and pulmonary embolism in pregnancy and the postpartum period. Aust N Z J Obstet Gynaecol 2012; 52 : 14-22.  Back to cited text no. 13
    
14.
Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 : e691S-736S.  Back to cited text no. 14
    
15.
Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 : e419S-96S.  Back to cited text no. 15
    
16.
Linkins LA, Dans AL, Moores LK, Bona R, Davidson BL, Schulman S, et al. Treatment and prevention of heparin-induced thrombocytopenia: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 : e495S-530S.  Back to cited text no. 16
    
17.
Liew NC, Alemany GV, Angchaisuksiri P, Bang SM, Choi G, DE Silva DA, et al. Asian venous thromboembolism guidelines: Updated recommendations for the prevention of venous thromboembolism. Int Angiol 2017; 36 : 1-20.  Back to cited text no. 17
    
18.
Zheng J, Chen Q, Fu J, Lu Y, Han T, He P. Critical appraisal of international guidelines for the prevention and treatment of pregnancy-associated venous thromboembolism: A systematic review. BMC Cardiovasc Disord 2019; 19 : 199.  Back to cited text no. 18
    
19.
Vora S, Ghosh K, Shetty S, Salvi V, Satoskar P. Deep venous thrombosis in the antenatal period in a large cohort of pregnancies from western India. Thromb J 2007; 5 : 9.  Back to cited text no. 19
    
20.
Sugiura-Ogasawara M, Ebara T, Matsuki T, Yamada Y, Omori T, Matsumoto Y, et al. Endometriosis and recurrent pregnancy loss as new risk factors for venous thromboembolism during pregnancy and post-partum: The JECS birth cohort. Thromb Haemost 2019; 119 : 606-17.  Back to cited text no. 20
    



 
 
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