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New Recommendations to Prevent Blood Clots During Cesarean Deliveries Issued

August 22, 2011

Washington, DC -- In an effort to reduce maternal mortality due to blood clots—a leading cause of maternal death in the US—The American College of Obstetricians and Gynecologists (The College) now recommends that all women having a cesarean delivery receive preventive intervention at the time of delivery. The new recommendation was released today along with updated guidance for the prevention, management, and treatment of blood clots during pregnancy.

Thromboembolism—blood clots which can potentially block blood flow and damage the organs—is a leading cause of maternal morbidity and mortality in the US. The majority of blood clots in pregnant women are venous thromboembolism (VTE), usually occurring within the deep veins of the left leg. "Cesarean delivery is an independent risk factor for thromboembolic events—it nearly doubles a woman's risk," said Andra H. James, MD, who helped develop the guidelines. Most women who develop clots in the lower extremities will have pain or swelling in the leg. Sometimes, clots travel to the lungs causing a life-threatening condition known as pulmonary embolism. Symptoms include sudden shortness of breath, chest pain, and coughing.

"Fitting inflatable compression devices on a woman's legs before cesarean delivery is a safe, potentially cost-effective preventive intervention," said Dr. James. "Inflatable compression sleeves should be left in place until a woman is able to walk after delivery or—in women who had been on blood thinners during pregnancy—until anticoagulation medication is resumed." The College notes, however, that an emergency cesarean delivery should not be delayed for the placement of compression devices.

Pregnancy is associated with a four-fold increase in the risk of thromboembolism. Clotting problems are more common among pregnant women because of the physiological changes that accompany pregnancy, such as blood that clots more easily, slower blood flow, compression of pelvic and other veins, and decreased mobility. Other risk factors include a personal history of VTE, an increased tendency for excessive clotting (thrombophilia), and medical factors such as obesity, hypertension, and smoking.

"VTE is a major contributor to maternal mortality in this country. The risk of VTE is increased during pregnancy and the consequences can be severe," said Dr. James. The recommendations explain how to monitor women for these events, address certain risk factors, and treat suspected or acute cases of VTE. "It's important for ob-gyns to adopt these recommendations to help reduce maternal deaths."

The College recommends preventive treatment with anticoagulant medication for women who have had an acute VTE during pregnancy, a history of thrombosis, or those at significant risk for VTE during pregnancy and postpartum, such as women with high-risk acquired or inherited thrombophilias. Women with a history of thrombosis should be evaluated for underlying causes to determine whether anticoagulation medication is appropriate during pregnancy. Most women who take anticoagulation medications before pregnancy will need to continue during pregnancy and postpartum.

"Because half of VTE-related maternal deaths occur during pregnancy and the rest during the postpartum period, ongoing patient assessment is imperative," Dr. James noted. "While warning signs in some women may be evident early in pregnancy, others will develop symptoms that manifest later in pregnancy or after the baby is born."

Practice Bulletin #123 "Thromboembolism in Pregnancy" is published in the September 2011 issue of Obstetrics & Gynecology.

The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation's leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of approximately 55,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women's health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org


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