Prevention of thrombosis in pregnancy: how practical are consensus derived clinical practice guidelines?
Thromboembolic disease (TED) has, for many years, consistently been identified as one of the leading causes of direct maternal mortality. In November 2009, the RCOG published a guideline on the prevention of TED that has been rapidly adopted by hospital trusts in the UK. The aim of our study was to determine the number and profile of women in our population that would require treatment with low molecular weight heparin (LMWH) and the cost implications of such treatment if these guidelines were implemented. A retrospective review of the first 100 women who delivered at the Coombe Women & Infants University Hospital (CWIUH) in 2010 was conducted and risk stratification applied at the relevant time points. A total of 51% were deemed to be at intermediate or high risk of TED at some point during pregnancy. In 35 of the 51 women (70%), this risk was attributable to factors such as age>35 years, parity≥3, BMI>30 kg/m2 or cigarette smoking. In our obstetric population, the percentage of women with these risk factors was: 25.5%, 8.5%, 19% and 16.7%, respectively. Implementation of this guideline would increase the hospital annual expenditure on LMWH by a factor of 17. The strategy of attributing risk by accumulating factors that individually have a low risk of TED and are prevalent in the population needs to be re-visited. The cost of implementation of these guidelines is not inconsiderable in the absence of data to indicate that clinical outcome is improved with their implementation.
RCSI Department of Obstetrics and Gynaecology, Coombe Women & Infants University Hospital (CWIUH), Dublin, Ireland.
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D000328:Adult; D000925:Anticoagulants / Q000627:therapeutic use; D032921:Consensus; D005260:Female; D006495:Heparin, Low-Molecular-Weight / Q000627:therapeutic use; D006771:Hospitals, Maternity; D006801:Humans; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011249:Pregnancy Complications, Cardiovascular / Q000517:prevention & control*; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013923:Thromboembolism / Q000517:prevention & control*; D006113:United Kingdom
D000925:Anticoagulants; D006495:Heparin, Low-Molecular-Weight