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Postpartum venous thromboembolism prophylaxis may cause more harm than benefit: a critical analysis of international guidelines through an evidence-based lens.

ABSTRACT: Based on prediction models and expert opinion, most obstetric venous thromboembolism guidelines recommend low-molecular-weight heparin for many postpartum women, including most delivering by caesarean. Scrutiny reveals major oversights: prediction models are based on studies that report asymptomatic deep vein thrombosis; risk estimates are not adjusted for time exposure; and harm caused by heparin has been overlooked. The benefits of heparin are exaggerated and its harms are under-appreciated. Estimates of the numbers-needed-to-treat and harm are universally lacking. This paper critically reviews the evidence and quantifies the benefit and harm from low-molecular-weight heparin in postpartum women with common risk factors.

Funding

This work was unsponsored and unfunded.

Tweetable abstract

Randomised trials should demonstrate more benefit than harm before widespread postpartum low-molecular-weight heparin is recommended.

SUBMITTER: Kotaska A

PROVIDER: S-EPMC6055738 | biostudies-literature | 2018 Aug

REPOSITORIES: biostudies-literature

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Postpartum venous thromboembolism prophylaxis may cause more harm than benefit: a critical analysis of international guidelines through an evidence-based lens.

Kotaska A A

BJOG : an international journal of obstetrics and gynaecology 20180307 9

Based on prediction models and expert opinion, most obstetric venous thromboembolism guidelines recommend low-molecular-weight heparin for many postpartum women, including most delivering by caesarean. Scrutiny reveals major oversights: prediction models are based on studies that report asymptomatic deep vein thrombosis; risk estimates are not adjusted for time exposure; and harm caused by heparin has been overlooked. The benefits of heparin are exaggerated and its harms are under-appreciated. E ...[more]

PMID: 29512316

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Project description:Extended venous thromboembolism prophylaxis (EVTEP) with low-molecular weight heparin such as enoxaparin for 28 days following surgery for cancer significantly reduces venous thromboembolic events compared to a standard 6-10 day course. National Institute of Clinical Excellence (NICE) guidelines suggest EVTEP should be offered to patients undergoing colorectal cancer surgery. Local EVTEP prescribing and monitoring guidelines in a busy inner city teaching hospital colorectal surgery unit, were devised to ensure NICE guidelines are followed. Adherence to local EVTEP guidelines was recorded through a retrospective audit of patients undergoing elective colorectal cancer surgery during February 2011 (n=19). Prospective re-audit cycles were undertaken during April-May (n=17) and September-December 2012 (n=17). The first audit cycle revealed that overall standards were not being met with just 11% of 'at risk' patients being correctly identified in pre-operative assessment clinic and continued low adherence to guidelines on the ward with only 44% of patients being prescribed EVTEP at discharge. Following each audit cycle, educational interventions were directed towards the multi-disciplinary team involved in the care of patients undergoing colorectal cancer surgery. This involved education of the team members regarding EVTEP, presentation of the audit results with instruction for improvement. Results of the second and third audit cycles showed improvements in guideline adherence with 100% of patients in these cohorts having been prescribed EVTEP at discharge. Marked improvements were also seen in the correct identification of 'at risk' patients, patient education in pre-operative assessment clinic, and warning of potential side-effects. This project has shown a significant global improvement in EVTEP-related patient care and adherence to local guidelines following education of the multi-disciplinary team involved, which consequently reduced the risk of venous thromboembolism within this patient cohort.

Dataset Information

Postpartum venous thromboembolism prophylaxis may cause more harm than benefit: a critical analysis of international guidelines through an evidence-based lens.

Funding

Tweetable abstract

Publications

Postpartum venous thromboembolism prophylaxis may cause more harm than benefit: a critical analysis of international guidelines through an evidence-based lens.

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