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Researchers Identify Risk Factors for Venous Thromboembolism in Women with Obesity Who Undergo Cesarean Delivery Free

July 31, 2024

August 2024

Lara C. Pullen, PhD

Lara C. Pullen, PhD, is a freelance medical writer in Chicago, Illinois.

Obstetricians recognize that the prevalence and morbidity of venous thromboembolism (VTE) in the peripartum period contributes significantly to maternal death. New research indicates that important risk factors for VTE in women with obesity who undergo cesarean delivery include endometritis, intra- or post-operative transfusion, coagulopathy, and urinary tract infection. Tolulope B. Fatokun, MD, an obstetrician-gynecologist at Cumberland Regional Hospital in Somerset, Kentucky, and colleagues published their findings in Clinical and Applied Thrombosis/Hemostasis. They concluded that, for patients who possess one or more of these risk factors, the addition of prophylactic anticoagulation to standard mechanical VTE prophylaxis may significantly decrease the risk of VTE and the downstream associated morbidity and mortality.

The investigators used data from the 1999-2002 Maternal-Fetal Medicine Units (MFMU) Network Cesarean Registry Database, which included more than 30,000 women who underwent cesarean delivery. Senior investigator Homa K. Ahmadzia, MD, MPH, a maternal-fetal medicine specialist at the George Washington University School of Medicine and Health Sciences in Washington, DC, explained that the team chose this database because, although it consisted of somewhat older data and did not include information on inherited thrombophilia, it had the advantages of being free and accessible, and it contained data from large numbers of patients. The researchers defined cases as women with obesity who had a pre-pregnancy body mass index (BMI) higher than 30 kg/m2, underwent cesarean delivery, and subsequently developed deep vein thrombosis (DVT) or pulmonary embolism (PE). They identified 43 (0.31%) peripartum VTE cases from the study population of 13,784 women with obesity who delivered via cesarean section and found that women with class III obesity (BMI≥40) had significantly higher rates of VTE (0.75%) compared to women with class I obesity (BMI=30.0-34.9; rate of 0.23%) and class II obesity (BMI=35.0-39.9; rate of 0.28%).

The team matched the VTE cases to 172 control cases of women with obesity who underwent cesarean delivery and did not develop DVT or PE. They then analyzed the data using the Chi-Square test and Fisher’s exact test in a case-control design. The authors recognized that a limitation of their data analysis was not using a multivariable model. The investigators calculated an increased risk of VTE in women with endometritis (odds ratio [OR] = 4.58 [95% CI 1.86-11.2; p=0.0004]), receiving a blood transfusion (OR=17.07 [95% CI 4.46-65.3; p=0.0001]), having a coagulopathy (OR=27.73 [95% CI 3.24-237.25; p=0.0003]), and having urinary tract infection (OR=2.39 [95% CI 1.08-5.28; p=0.0284]).

The authors reported that their findings are consistent with previous studies that demonstrated that a history of coagulopathy, systemic infection, and postpartum hemorrhage or blood transfusion were associated with an increased risk of thrombosis and that women who received blood transfusion during or after cesarean delivery were more likely to develop both early and late DVT. Despite these previous studies, however, “there are still many women who have clots that we don’t predict,” Dr. Ahmadzia said. “I am a huge advocate for prevention and better patient education on warning signs and symptoms,” she added. “Let’s be more proactive.”

This proactivity includes obtaining a better understanding of the physiology behind the risk factors for both bleeding and clotting in the peripartum period. Dr. Ahmadzia noted, for example, that in the case of blood transfusion, women were not only a high risk for bleeding, but also for clotting. “Do we understand why?” she asked. “Not really. We still do not fully understand etiology of postpartum hemorrhage or how to optimally prevent it. Poor uterine tone is not always an issue in severe hemorrhages.”

She said additional research in hemostasis and thrombosis in the peripartum period is incredibly important. To that end, her research group recently received an NIH R01 grant to study the optimal use of tranexamic acid for prevention of postpartum hemorrhage, and she hopes to further scientific progress in this understudied population.

Any conflicts of interest declared by the authors can be found in the original article.

Reference

Fatokun TB, Swartz SE, Ebeid A, et al. Venous thromboembolism risk factors in women with obesity who undergo cesarean delivery. Clin Appl Thromb Hemost. 2024;30. doi: 10.1177/10760296241247203.

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