Thromboembolism Prophylaxis Could Reduce Maternal Deaths After C-Section

Although most maternal deaths are not preventable, thromboembolism prophylaxis could reduce death rates in women undergoing cesarean delivery, according to a report in the July American Journal of Obstetrics & Gynecology.

“We have already successfully implemented the universal use of pneumatic compression devices for all cesarean patients in 96% of our facilities providing obstetric care, and will bring the remaining facilities into compliance by year’s end,” Dr. Steven L. Clark from Hospital Corporation of America, Salt Lake City, Utah told Reuters Health. “We have seen no significant resistance. It seemed like such a natural thing to do that our hospitals and the physicians practicing there have eagerly adopted this policy in order to improve patient safety.”

Dr. Clark and colleagues examined the etiology and preventability of maternal death and the causal relationship of cesarean delivery to maternal death in a series of about 1.5 million deliveries between 2000 and 2006.

Among the total of 95 maternal deaths during this period, 45 were classified as direct obstetric deaths, 32 as indirect obstetric deaths, and 18 as nonobstetric deaths, the authors report.

Preexisting medical conditions caused or contributed to the death of 14 women, the report indicates, and 2 women died after a dilatation and curettage procedure related to spontaneous abortion.

Only 17 deaths were deemed preventable with more appropriate medical care, whereas 10 deaths were judged to have been preventable but were due to actions or inactions of nonmedical persons, including 2 motor vehicle accidents, 2 antepartum suicides, 2 cases of ethanol abuse and 4 cases of noncompliance or failure to access medical care.

Four deaths were attributed directly to cesarean delivery and 2 deaths were felt to be causally related to vaginal delivery.

In addition, 9 women died from pulmonary thromboembolism, 6 after cesarean delivery, 1 following repeat cesarean delivery, and 2 after vaginal birth. None of these women had received peripartum thromboembolism prophylaxis, the investigators say.

“Given the diversity of causes of maternal death,” the authors conclude, “no systematic reduction in maternal death rate in the United States can be expected unless all women undergoing cesarean delivery receive thromboembolism prophylaxis.”

“The use of perioperative venous thromboembolism (VTE) prophylaxis is already an accepted part of virtually every other type of major operation in the United States — in effect, hospitals only need to give the level of care to pregnant women that they have been giving to non-pregnant women and men for years,” Dr. Clark said. “Thus, no dramatic new protocols or policies need be adopted.”

“Next year we will compare the incidence of venous thrombotic events in our system following implementation of universal VTE prophylaxis measures with that in past years before the implementation of such measures,” he added. “While our article specifically addressed the worst possible type of VTE (fatal pulmonary embolism) we expect that the use of such prophylactic measures will also reduce the more frequent but less dramatic morbidity resulting from non-fatal VTE events.”

Am J Obstet Gynecol 2008;199:36.e1-36.e5.

Reviewed by Ramaz Mitaishvili, MD

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