To estimate the rate of wound complications associated with protocol-driven postcesarean enoxaparin thromboprophylaxis.
After implementing an Institutional Clinical Practice Guideline for postoperative cesarean delivery thromboprophylaxis among at-risk gravid women (older than 35 years of age, body mass index greater than 30 kg/m2, or both), data on all cesarean deliveries over the first 23 months of guideline implementation were extracted and analyzed. Primary (wound hematoma, separation, or dehiscence) and secondary (venous thromboembolism) outcomes were compared in stratified and multivariable models controlling for potential confounders.
Over 23 months, 2,509 cesarean deliveries were performed. A total of 1,677 (68%) gravid women met criteria for thromboprophylaxis; 653 received enoxaparin per protocol ("cases"), and, at the discretion of the ordering physician, 1,024 did not (at-risk, protocol-noncompliant "controls"). Cases differed significantly by virtue of maternal age, body mass index, and diabetic status. Univariable analysis subsequently revealed a higher rate of wound separation (6.8% compared with 3.6%, P=.003), rehospitalization (2.1% compared with 0.8%, P=.017) and composite score (8.9% compared with 4.8%, P=.002) among protocol-compliant cases, but no increased risk of wound hematoma (P>.06). In multivariable analysis, adjusted odds ratios continued to reveal an association between enoxaparin use and wound separation (OR 1.66, P=.04) as well as higher composite score (OR 1.69, P=.01). However, among the protocol-noncompliant controls, a nonsignificant increase in the rate of venous thromboembolism occurred.
In our series, prophylactic enoxaparin use among at-risk gravid women undergoing cesarean delivery was accompanied by an increased risk of wound separation.
[Show abstract][Hide abstract] ABSTRACT: The aim of the 2012 "What's new in obstetric anesthesia?" review is to highlight important scientific and medical advances in the fields of obstetric anesthesiology, obstetrics and perinatology from literature published in 2011. This review will consider advances in the prevention and treatment of important obstetric and obstetric anesthesia-related morbidities, research relevant to the course of labor and electronic fetal monitoring, and advances in neuraxial analgesia and anesthesia for obstetric patients.
International journal of obstetric anesthesia 09/2012; 21(4):348-56. DOI:10.1016/j.ijoa.2012.08.005 · 1.60 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Introduction:
The objective of this study was to compare wound and bleeding complications between women who received anticoagulation after cesarean delivery due to history of prior venous thromboembolic disease, arterial disease, or being a thrombophilia carrier with adverse pregnancy outcome, to women not receiving anticoagulation.
Women in the Duke Thrombosis Center Registry who underwent cesarean delivery during 2003-2011 and received postpartum anticoagulation (anticoagulation group, n=77), were compared with a subset of women who delivered during the same time period, but did not receive anticoagulation (no anticoagulation group, n=77). The no anticoagulation group comprised women who were matched to the anticoagulation group by age, body mass index, type of cesarean (no labor vs. labor), and date of delivery. Bleeding and wound complications were compared between the two groups. A multivariable logistic regression model was constructed to determine if anticoagulation was an independent predictor of wound complication.
Women who received anticoagulation during pregnancy had a greater incidence of wound complications compared to those who did not (30% vs. 8%, p<0.001). Using multivariable logistic regression, while controlling for race, diabetes, chorioamnionitis, and aspirin use, anticoagulation predicted the development of any wound complication (OR 5.8, 95% CI 2.2, 17.6), but there were no differences in the mean estimated blood loss at delivery (782 vs. 778 ml, p=0.91), change in postpartum hematocrit (5.4 vs. 5.2%, p=0.772), or percent of women receiving blood products (6.5 vs. 1.3%, p=0.209) between the two groups.
Anticoagulation following cesarean delivery is associated with an increased risk of post-cesarean wound complications, but not other postpartum bleeding complications.
Thrombosis Research 06/2013; 132(1). DOI:10.1016/j.thromres.2013.04.034 · 2.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective:
Pregnancy is associated with increased risk for thromboembolic events. Intermittent pneumatic compression (IPC) devices are the method of thromboprophylaxis in a nonpregnant population. The aim of this study was to examine the effects of IPC on markers of fibrinolysis during cesarean delivery.
We conducted a randomized controlled trial from April 2009 to March 2010 of women undergoing scheduled elective cesarean delivery. Forty-nine women were randomized to IPCs or usual care. All participants had three blood samples obtained: (1) baseline, (2) 1 hour after randomization, and (3) 30 minutes after cesarean delivery. Tissue-type plasminogen activator (tPA), urokinase-type plasminogen activator (uPA), thrombin-antithrombin complex (TAT), plasminogen activator inhibitor-1 (PAI-1), and plasminogen activator inhibitor-2 (PAI-2) levels were analyzed in each sample using an enzyme-linked immunosorbent assay. Statistical analysis was performed using repeated measures two-way analysis of variance with α = 0.05.
There was a time-dependent change in tPA, uPA, and PAI-1 levels following delivery but no difference in TAT and PAI-2 levels with time. There were no differences between women randomized to IPCs or usual care.
Markers of fibrinolysis were not significantly altered by IPCs in this study of low-risk pregnant women. Further research regarding the mechanism and efficacy of IPCs in pregnant women is warranted.
American Journal of Perinatology 12/2013; 31(09). DOI:10.1055/s-0033-1359720 · 1.91 Impact Factor
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