Venous thromboembolism in pregnancy: 21-year trends

doi:10.1016/j.amjmed.2004.02.021

The American Journal of Medicine

Volume 117, Issue 2, 15 July 2004, Pages 121-125

https://doi.org/10.1016/j.amjmed.2004.02.021 Get rights and content

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Data sources

Data were abstracted from the National Hospital Discharge Survey 10, 11, which is based on a national probability sample of discharges from noninstitutional hospitals, exclusive of federal, military, and Veterans Affairs hospitals, in the 50 states and the District of Columbia. The sampling plan, performed in three stages, has been described elsewhere 10, 11, 12. We evaluated women aged 15 to 44 years, which included 99.6% of all maternities, from 1979 to 1999.

The survey design, sampling, and

Results

The rate of diagnosis of pregnancy-associated deep venous thrombosis increased from 1979 to 1999 (Figure 1). Women who were pregnant had a 2.33-fold greater rate of diagnosis (95% confidence interval [CI]: 2.31 to 2.35; P <0.0001) compared with nonpregnant women. Older age, being black, and delivery by cesarean section were associated with higher rates of deep venous thrombosis (Table 1). Deliveries among patients aged 35 to 44 years increased linearly from 5% (158,000/3,482,000) to 13%

Discussion

We found a distinct upward trend for pregnancy-associated deep venous thrombosis during the 21-year period from 1979 to 1999, which contrasts markedly with the declining trend for deep venous thrombosis in nonpregnant women. The reasons for these diverging trends are unknown. Perhaps the increasing trend in cases of pregnancy-associated deep venous thrombosis reflects increased clinician awareness and diagnostic surveillance, or increasing comorbidity during the 21-year period, which previously

Acknowledgements

The authors thank Robert Pokras, MA, Paul D. Sutton, PhD, and Stephanie Ventura, MA, Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, Maryland, for their assistance. We also thank Kalpesh C. Patel, MBBS, Rita Biel, and Jeanne Sheldon for their assistance with this manuscript.

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Venous thrombosis and thromboembolism (VTE) remain the leading cause of direct maternal deaths, occurring within 42 days of the end of pregnancy in the UK. Pregnancy is associated with an overall 10-fold higher incidence of VTE than in the non-pregnant state and has been reported to reach up to 30-fold higher in the puerperium. This increased risk is further exacerbated by maternal obesity in a relationship that appears to be proportional with increasing Body Mass Index (BMI).
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The median absolute VTE risk during pregnancy is reported to be 5.7 per 10,000 deliveries, with the preponderance of studies showing an increased risk of VTE through each passing trimester of pregnancy, a peak one to three weeks postpartum and then a decline in risk equivalent to a non-pregnant state by 12 weeks postpartum.1–8 The increased hypercoagulable state brought on by the physiological changes during pregnancy is likely an evolutionary protective mechanism against hemorrhaging during childbirth, but it also marks pregnancy as a strong risk factor for VTE.1,9–11 Other pregnancy-related VTE risk factors are decreased venous outflow in the pelvic vasculature due to uterine compression, decreased mobility, and vascular injury from maternal complications such as preeclampsia and eclampsia.5,9,11–13
In the U.S., deaths due to pulmonary embolism (PE) account for 9.2% of all pregnancy-related deaths or approximately 1.5 deaths per 100,000 live births. Maternal deaths and maternal morbidity due to PE are more common among women who deliver by cesarean section. In the past decade, the clinical community has increasingly adopted venous thromboembolism (VTE) guidelines and thromboprophylaxis recommendations for pregnant women. Although deep vein thrombosis rates have decreased during this time-period, PE rates have remained relatively unchanged in pregnancy hospitalizations and as a cause of maternal mortality. Changes in the health profile of women who become pregnant, particularly due to maternal age and co-morbidities, needs more attention to better understand the impact of VTE risk during pregnancy and the postpartum period.
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2016, Obstetrics: Normal and Problem Pregnancies
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2016, International Journal of Gynecology and Obstetrics
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Almost all studies focused on the issues of interest in the present review and used appropriate and accepted methods to answer the corresponding research questions [3,7–10,17–20,22–30]. Recruitment of cases, controls, and cohorts had been conducted in an acceptable way in all case–control studies [6–8,23–25] and in 13 of the 14 cohort studies [3,9,10,17–20,22,26–30]. Only one retrospective cohort study seemed to have inaccurate measurement of exposure and outcome [21].
Pregnancy-related venous thromboembolism (VTE) is one of the leading causes of maternal morbidity and mortality.
To review the epidemiology, and humanistic and economic burden of pregnancy-related VTE.
Medline, the Cochrane Central Register of Controlled Trials, Econlit, Science Direct, JSTOR, Oxford Journals, and Cambridge Journals were searched for reports published between January 2000 and December 2012. Keywords related to VTE, pregnancy, and epidemiology and the humanistic and economic burdens were combined.
Eligible studies evaluated the incidence, mortality, recurrence, complications, quality-of-life, and economic burden of VTE among pregnant women, and had been published in English.
Background information of the study, participants’ characteristics, and study outcomes were collected. Meta-analyses of data were performed.
Twenty studies were included, none of which investigated the economic burden. The pooled overall incidence of pregnancy-related VTE was 1.2 per 1000 deliveries. The pooled VTE case fatality rate was 0.68% and the recurrence rate was 4.27%. The pooled risk of major bleeding was 1.05%. Post-thrombotic syndrome seemed to have a negative effect on quality of life.
Although the incidence of VTE was found to be relatively low during pregnancy and the postpartum period, the clinical burden is high. Further research is required to assess the economic burden of pregnancy-relate VTE.
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2014, Revista Medica Clinica Las Condes
La incidencia de Tromboembolismo Venoso (TEV) en el embarazo se incrementa aproximadamente de 4 a 50 veces más en comparación con mujeres no embarazadas, debido a las modificaciones que el propio embarazo produce sobre los factores de la coagulación y los sistemas fibrinolíticos. Se estima que la TEV complica entre 1 y 1,5 por cada 1.000 embarazos. Durante el embarazo la hemostasia materna se caracteriza por ser un estado protrombótico en el cual se producen cambios en el sistema hemostático, con el objetivo de prevenir una posible hemorragia durante las primeras etapas del embarazo, parto y puerperio. Sin embargo, la adaptación del sistema hemostático materno al embarazo predispone a la madre a un riesgo incrementado de TEV.
El diagnóstico de los eventos tromboembólicos en el embarazo constituye un reto para los equipos tratantes, ya que los hallazgos clínicos y de laboratorio característicos de esta enfermedad pueden estar enmascarados en los cambios fisiológicos propios de la gestación, por lo que el inicio de su evaluación suele ser complejo.
Para el correcto y oportuno diagnóstico de TVP y TEP se requiere de una combinación de varios elementos que incluye: síntomas y signos, estudios de laboratorio e imagenología.
El uso de anticoagulantes en pacientes obstétricas requiere de un plan de interrupción del embarazo lo más controlado posible. En la práctica clínica cotidiana esto no siempre es posible, debido a la incapacidad de predecir el momento de inicio del trabajo de parto. Por este motivo las recomendaciones relativas al manejo analgésico y anestésico del parto están basadas en el conocimiento de los cambios fisiológicos, farmacocinético y farmacodinámico de los anticoagulantes utilizados, lo que se analiza en extenso en esta revisión.
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The diagnosis of thromboembolic events in pregnancy is a challenge for the Maternal fetal specialists as clinical and laboratory findings that are a characteristic of this disease, may be masked on own physiological changes of pregnancy, making the startup of the evaluation often complex.
For the proper and timely diagnosis of DVT and PE, a combination of several elements is required, including: symptoms and signs, laboratory and imaging studies.
The use of anticoagulants in obstetric patients requires a controlled plan for the moment of labor and delivery. In everyday clinical practice, this is not always possible due to the inability to predict the time of onset of labor. For this reason, the recommendations relating to the analgesic and anesthetic management of labor are based on knowledge of the physiological, pharmacokinetic and pharmacodynamics changes of anticoagulant used, which is discussed at length in this review.

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Brief observationVenous thromboembolism in pregnancy: 21-year trends

Section snippets

Data sources

Results

Discussion

Acknowledgements

First page preview

Obstet Gynecol

Womens Health Issues

Am J Obstet Gynecol

Cardiovasc Surg

Maternal mortality in the United States, 1979–1986

Obstet Gynecol

Pregnancy-related mortality surveillance—United States, 1987–1990

MMWR Morb Mortal Wkly Rep

Why Mothers Die, Report on Confidential Enquiries into Maternal Deaths in the United Kingdom, 1994–1996

Maternal mortality in Sweden, 1980–1988

Obstet Gynecol

Maternal mortality in the United Statesreport from the Maternal Mortality Collaborative

Obstet Gynecol

The cumulative incidence of venous thromboembolism during pregnancy and puerperium—an 11 year Danish population-based study of 63,000 pregnancies

Acta Obstet Gynecol Scand

Venous thromboembolic disease in obstetrics and gynaecologythe Scottish experience

Scot Med J

Obstetrical pulmonary embolism mortality, United States, 1970–85

Am J Public Health

Design and operation of the National Hospital Discharge Survey1988 redesign

Vital Health Stat 1

Brief observation
Venous thromboembolism in pregnancy: 21-year trends