Thromboembolism prophylaxis and cesarean section. (Editorial).

Venous thromboembolism is extremely underrepresented in the obstetric literature, yet it is the leading cause of obstetric death. Cesarean section remains a significant contributing factor in thromboembolic disease, yet textbooks (1,2) currently emphasize treatment and fail to address the prevention of venous thromboembolism adequately. The long-term sequelae of venous thromboembolism include chronic edema, pain, and recurrent thrombosis due to vascular injury. Prevention remains the best and most appropriate option in those patients most at risk for venous thromboembolism.

In this issue of the Southern Medical Journal, Thomas Connolly, DO, (3) reports the results of a regional survey of practicing obstetricians and evaluates their responses to risk factors for venous thromboembolism. The number of responses to the survey is limited (n = 51), but the survey responses adequately demonstrate a pattern that is likely to be consistent throughout the United States and previously was shown among practitioners of maternal-fetal medicine. (4) Less than half of the respondents were willing to order risk factor prophylaxis (except in those patients with a history of venous thromboembolism or a family history of thromboembolism), despite a reported 10-fold increase in thromboembolism after cesarean section. Eliminating the second most frequent indication resulting in prophylaxis, cesarean hysterectomy, resulted in only 22% of respondents indicating a willingness to order prophylaxis for venous thromboembolism, despite the remaining risks.

The results of this survey and the lack of consensus among obstetricians in their current practice demonstrate a failure to prevent the most common cause of maternal death. In the era of increasing cesarean section rates and the trend away from vaginal birth after cesarean section, it is imperative that physicians improve the safety of current practices. The readily available approaches to decrease the risk of venous thromboembolism in patients undergoing cesarean section provide obstetricians with an opportunity that they cannot afford to miss.

Accepted July 18, 2002.

References

(1.) Gabbe SG. Niebyl JR, Simpson JL (eds). Obstetrics: Normal and Problem Pregnancies. New York, Churchill Livingstone, 2002, ed 4.

(2.) Creasy RK, Resnik R (eds). Maternal-Fetal Medicine. Philadelphia, W.B. Saunders Co., 1999, ed 4.

(3.) Connolly T. Thromboembolism prophylaxis and cesarean section: A survey of general obstetricians. South Med J 2003;96:146-148.

(4.) Evans W, Laifer SA, MeNanley TJ, Ruzycky A. Management of thromboembolic disease associated with pregnancy. J Matern Fetal Med 1997;6:21-27.

From thc Department of Obstetrics/Gynecology, Quillen College or Medicine, East Tennessee State University, Johnson City, TN.

Reprint requests to William A. Block, Jr., MD, FACOG, Department of Obstetrics/Gynecology, Quillen College of Medicine, East Tennessee State University, Box 70569, 307 VA-Carl A. Jones Hall, Mountain Home, TN 37684. Email: [e-mail]

Copyright [c] 2003 by The Southern Medical Association 0038-4348/03/9602-0121