DVT Prophylaxis in Pregnancy.

We all know that pregnancy is a risk factor for venous thromboembolism. The incidence is up to 500% higher for pregnant women than for nonpregnant women. One study reported up to a 3% incidence of deep vein thrombosis post partum and about a 20% incidence of pulmonary embolism when an untreated DVT is present.

So why isn't it standard practice to treat pregnant patients with the same type of DVT prophylaxis as our gynecology patients? (I assume we all treat patients with a history of prior venous thromboembolism [VTE], but they represent a very small minority of our patients.)

Why don't we use antiembolism stockings or pneumatic compression for our postop cesarean patients? Maybe not all of them, but at least a subset, such as those who are over 40 or obese, or those with severe varicose veins. What about our preterm labor patients on prolonged bed rest? I asked many of my colleagues and none uses VTE prophylaxis for obstetric patients.

The number-one cause of maternal death in this country is thromboembolic disease. Years ago, I had a young postpartum patient die from a pulmonary embolism (PE) at home 3 days after discharge. I subsequently went through a 17-day jury trial. One of the key points frequently emphasized during the trial was that pregnant women are at high risk for forming blood dots. Yet, what do we do about this with our pregnant patients? Generally nothing.

This topic has almost never been addressed in the literature. In a 1996 article about VTE during pregnancy other than for patients with a prior history of VTE, there was not one word about VTE prophylaxis, nor was there any mention of it in the American College of Obstetricians and Gynecologists' Bulletin Number 234 on thromboembolism in pregnancy. However, in a 1999 article, Dr. John Bonnar of Trinity College in Dublin, Ireland, had a lot to say about this topic (Am. J. Obstet. Gynecol. 180[4]:784-91, 1999).

Dr. Bonnar made a very ...