ImportanceIn 2016, our institution adopted a pregnancy-related venous thromboembolism (VTE) prophylaxis protocol based on American College of Obstetricians and Gynecologists guidelines that recommended postpartum heparin-based chemoprophylaxis (enoxaparin) based on a risk-stratified algorithm. In response to increased wound hematomas without significant reduction in VTE using this protocol, a more selective risk-stratified approach was adopted in 2021.ObjectiveTo evaluate outcomes of the more selective risk-stratified approach to heparin-based obstetric thromboprophylaxis (enoxaparin) protocol.Design, Setting, and ParticipantsRetrospective observational study of 17 489 patients who delivered at a single tertiary care center in the southeast US between January 1, 2016, and December 31, 2018 (original protocol), and between December 1, 2021, and May 31, 2023 (more selective protocol). Patients receiving outpatient anticoagulation for active VTE or high VTE risk during pregnancy were excluded.ExposureStandard risk-stratified and more selective postpartum VTE chemoprophylaxis protocols.Main Outcomes and MeasuresThe primary outcome was clinical diagnosis of wound hematoma up to 6 weeks pos tpartum. The secondary outcome was new diagnosis of VTE up to 6 weeks post partum. We compared baseline characteristics and outcomes between groups and estimated adjusted odds ratios with 95% CIs of primary and secondary outcomes using the original protocol group as reference.ResultsOf 17 489 patients included in the analysis, 12 430 (71%) were in the original protocol group and 5029 (29%) were in the more selective group. Rates of chemoprophylaxis decreased from 16% (original protocol) to 8% (more selective protocol). Patients in the more selective group were more likely to be older, be married, and have obesity or other comorbidities (hypertension, diabetes, cardiac disease). Compared with the original protocol, the more selective protocol was associated with a decrease in any wound hematoma (0.7% vs 0.3%; adjusted odds ratio [aOR], 0.38; 95% CI, 0.21-0.67), specifically due to a lower rate of superficial wound hematomas (0.6% vs 0.3%; aOR, 0.43; 95% CI, 0.24-0.75). There was no significant increase in VTE or individual types of VTE (0.1% vs 0.1%; aOR, 0.40; 95% CI, 0.12-1.36).Conclusions and RelevanceA more selective risk-stratified approach to an enoxaparin thromboprophylaxis protocol for VTE was associated with decreased rates of wound hematomas without increased rates of postpartum VTE.

中文翻译：

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与标准风险分层、基于肝素的产科血栓预防方案相比，更具选择性


重要性2016 年，我们的机构根据美国妇产科学院指南采用了妊娠相关静脉血栓栓塞 (VTE) 预防方案，该方案建议基于风险分层算法的产后肝素化学预防（依诺肝素）。为了应对使用该方案的伤口血肿增加而 VTE 没有显着减少的情况，2021 年采用了更具选择性的风险分层方法。目的评估基于肝素的产科血栓预防（依诺肝素）方案的更具选择性的风险分层方法的结果。 、背景和参与者对 2016 年 1 月 1 日至 2018 年 12 月 31 日（原始方案）以及 2021 年 12 月 1 日至 5 月 31 日期间在美国东南部一个三级护理中心分娩的 17 489 名患者进行回顾性观察研究， 2023（更具选择性的协议）。因活动性 VTE 或怀孕期间高 VTE 风险而接受门诊抗凝治疗的患者被排除在外。暴露标准风险分层和更具选择性的产后 VTE 化学预防方案。主要结果和措施主要结果是产后 6 周内伤口血肿的临床诊断。次要结果是产后 6 周内新诊断出 VTE。我们比较了各组之间的基线特征和结果，并使用原始方案组作为参考，估计调整后的比值比与主要和次要结果的 95% CI。结果在分析中纳入的 17 489 名患者中，12 430 名患者 (71%) 接受原始方案组中 5029 人（29%）属于更具选择性的组。化学预防率从 16%（原始方案）下降至 8%（更具选择性的方案）。 选择性较高的组中的患者更有可能年龄较大、已婚、患有肥胖或其他合并症（高血压、糖尿病、心脏病）。与原始方案相比，更具选择性的方案与任何伤口血肿的减少相关（0.7% vs 0.3%；调整后优势比 [aOR]，0.38；95% CI，0.21-0.67），特别是由于血肿发生率较低浅表伤口血肿的发生率（0.6% vs 0.3%；aOR，0.43；95% CI，0.24-0.75）。 VTE 或个别类型的 VTE 没有显着增加（0.1% vs 0.1%；aOR，0.40；95% CI，0.12-1.36）。结论和相关性与 VTE 依诺肝素血栓预防方案的更具选择性的风险分层方法相关伤口血肿发生率降低，但产后 VTE 发生率不增加。