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Watch for Clots During the “Fourth Trimester”

February 13, 2014

Watch for Clots During the “Fourth Trimester”

  1. Eleanor Bimla Schwarz, MD, MS

Risk for thrombosis remains elevated for 12 weeks postpartum.

  1. Eleanor Bimla Schwarz, MD, MS

Women are hypercoagulable for the first 6 weeks postpartum, but the time course of thrombotic risk thereafter is unclear. To assess extended postpartum clot risk, researchers analyzed hospital discharge claims data from all California women who delivered between 2005 and 2010.

In models adjusted for factors such as age, race, smoking, and predisposition to clot, incidence of a first thrombotic event (ischemic stroke, acute myocardial infarction, or venous thrombosis) 7 to 12 weeks after delivery was twice that at 1 year postpartum, for an absolute risk difference of 3.0 thrombotic events per 100,000 deliveries. Thrombotic risk leveled off after 12 weeks postpartum.

Comment

Although we need further study of postpartum clot risk, I will now consider offering thrombotic prophylaxis to high-risk women throughout the first 12 weeks after delivery. In addition, although the CDC has stated that women without risk factors for thromboembolism can generally initiate estrogen-containing contraception 21 to 42 days after delivering (while women with cesarean deliveries or previous thrombosis should wait 42 days postpartum [NEJM JW Womens Health Jul 28 2011]), I will encourage my postpartum patients to wait 12 weeks before using estrogen-containing contraception. For those who want immediate postpartum contraception, intrauterine devices and implants offer highly effective reversible contraception without increasing clot risk.

Hooman Kamel, MD, is lead author of this study and an Associate Editor for NEJM Journal Watch Neurology, but had no role in the selection and preparation of this summary.

  • Disclosures for Eleanor Bimla Schwarz, MD, MS at time of publication Grant / research support AHRQ; American Diabetes Association; Department of Health and Human Services–Office of Population Affairs; FDA; Kellogg Foundation; NICHD; Society of Family Planning; VA; Women Veterans Health Editorial boards Contraception

Citation(s):

Reader Comments (5)

chris Azukaeme Physician, Emergency Medicine, teaching Hospital

ASA

Stephen F. Daugherty, MD Physician, Surgery, Specialized, VeinCare Centers of Tennessee

Elastic compression stockings should be worn during pregnancy to improve lower extremity venous outflow, to control edema, and to reduce the risk of lower extremity venous thrombosis. The results of this study lead me to believe that compression hose should be worn at least through the first 12 postpartum weeks as well.

Sunil Narayan Physician, Neurology, JIPMER, Pondicherry

Very useful paper

WILLIAM ROCK Physician, Pathology, U of Ms Med Center

Need more analysis of risk, with emphasis on post partum coagulation status

Xavier Prida Physician, Cardiology, St Joseph's Hospital, Tampa, Fl.

I will now consider offering thrombotic prophylaxis to high-risk women throughout the first 12 weeks after delivery.
As to the endpoint(s) to be prevented - What singular prophylaxis would be effective for prevention of 3 distinct mechanistic and anatomic events: ischemic stroke, myocardial infarction, and venous thrombosis? ASA ? Advanced antithrombotics- warfarin?

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