Risk Assessment Model for Postpartum Venous Thromboembolism Prevention in Patients with Systemic Lupus Erythematosus

Abstract

Objective This article assesses the application of the Royal College of Obstetricians and Gynaecologists (RCOG) venous thromboembolism (VTE) risk model on a cohort of postpartum patients with a history of systemic lupus erythematosus (SLE).

Study Design This is a secondary analysis of an ongoing patient registry of women with SLE from 2016 to 2022. There were 49 SLE patients with 55 pregnancies using the Definitions of Remission in SLE (DORIS) criteria to determine SLE disease activity. RCOG risk assessment model scoring was calculated for each patient prior to and after delivery. The primary outcome was the qualification of “active SLE” by standard rheumatologic criteria and assessment of recommendations for VTE prophylaxis based on RCOG VTE risk assessment scoring. Data were analyzed using Fisher's exact test, chi-square test, and Mann–Whitney U test with significance defined as p < 0.05.

Results In the study cohort, 34 pregnancies (61.8%) were in DORIS remission at delivery. Twenty-one pregnancies (38.2%) were not and scored 3 points on the RCOG VTE risk model. Of these pregnancies, only 19% (n = 4) were recommended for VTE prophylaxis by the obstetrical provider despite RCOG score ≥3. Only 35.7% (n = 5) of pregnancies in DORIS remission, but with 3 points for non-SLE-related VTE risk factors (n = 14), were recommended for VTE prophylaxis. Of the 20 pregnancies in remission with an RCOG score < 3 after assessing all risk factors, 15% (n = 3) were nevertheless recommended for VTE prophylaxis. No patients had a postpartum VTE regardless of therapy.

Conclusion These data reveal a need to improve upon providing postpartum VTE prophylaxis to SLE patients not in remission while also recognizing a diagnosis of SLE alone should not equate with active disease. Moreover, SLE patients in remission may still warrant VTE prophylaxis if other non-SLE-related risk factors are present.

Key Points

• Those with SLE are at increased risk for VTE postpartum.

• VTE prophylaxis should be instituted when clinically appropriate.

• Caution should be exercised in broadly assigning disease activity for SLE diagnosis only.

• This study supports VTE prophylaxis use in postpartum patients with SLE.

Keywords

systemic lupus erythematosus - venous thromboembolism - postpartum care

Note

This study was presented at the American College of Rheumatology Convergence 2022 Meeting, ACR, Philadelphia, PA, at November 10–14, 2022.

Condensation

Thromboprophylaxis should be instituted when clinically appropriate with caution exercised when assigning disease activity for the diagnosis of SLE alone on the RCOG VTE risk assessment model.

Ethics Approval

This study received IRB approval from the relevant NYU Langone Health IRB committee responsible for human experimentation. Reference number i14–00487, approved July 27, 2021.

Publikationsverlauf

Eingereicht: 17. Mai 2023

Angenommen: 09. Juni 2023

Artikel online veröffentlicht:
20. Juli 2023

• References

• 1 Division of Reproductive Health NCfCDPaHP. Pregnancy Mortality Surveillance System. 2020 . Accessed June 26, 2023 at: https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm#race-ethnicity
• 2 Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol 2015; 125 (01) 5-12
• 3 Callaghan WM, Creanga AA, Kuklina EV. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol 2012; 120 (05) 1029-1036
• 4 Pomp ER, Lenselink AM, Rosendaal FR, Doggen CJ. Pregnancy, the postpartum period and prothrombotic defects: risk of venous thrombosis in the MEGA study. J Thromb Haemost 2008; 6 (04) 632-637
• 5 Bleau N, Patenaude V, Abenhaim HA. Risk of venous thromboembolic events in pregnant patients with autoimmune diseases: a population-based study. Clin Appl Thromb Hemost 2016; 22 (03) 285-291
• 6 Danowski A, de Azevedo MN, de Souza Papi JA, Petri M. Determinants of risk for venous and arterial thrombosis in primary antiphospholipid syndrome and in antiphospholipid syndrome with systemic lupus erythematosus. J Rheumatol 2009; 36 (06) 1195-1199
• 7 Kotaska A. Postpartum venous thromboembolism prophylaxis may cause more harm than benefit: a critical analysis of international guidelines through an evidence-based lens. BJOG 2018; 125 (09) 1109-1116
• 8 ACOG Practice Bulletin No. 196: thromboembolism in pregnancy. Obstet Gynecol 2018; 132 (01) e1-e17
• 9 Caprini JA, Arcelus JI, Hasty JH, Tamhane AC, Fabrega F. Clinical assessment of venous thromboembolic risk in surgical patients. Semin Thromb Hemost 1991; 17 (Suppl. 03) 304-312
• 10 Barbar S, Noventa F, Rossetto V. et al. A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score. J Thromb Haemost 2010; 8 (11) 2450-2457
• 11 Sibai BM, Rouse DJ. Pharmacologic thromboprophylaxis in obstetrics: broader use demands better data. Obstet Gynecol 2016; 128 (04) 681-684
• 12 Gynaecologists RCoOa. Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium. RCOG. 2015; Green-top Guideline No. 37b
• 13 James AH, Jamison MG, Brancazio LR, Myers ER. Venous thromboembolism during pregnancy and the postpartum period: incidence, risk factors, and mortality. Am J Obstet Gynecol 2006; 194 (05) 1311-1315
• 14 Petri M, Kim MY, Kalunian KC. et al; OC-SELENA Trial. Combined oral contraceptives in women with systemic lupus erythematosus. N Engl J Med 2005; 353 (24) 2550-2558
• 15 Gladman DD, Ibañez D, Urowitz MB. Systemic lupus erythematosus disease activity index 2000. J Rheumatol 2002; 29 (02) 288-291
• 16 Thanou A, James JA, Arriens C. et al. Scoring systemic lupus erythematosus (SLE) disease activity with simple, rapid outcome measures. Lupus Sci Med 2019; 6 (01) e000365
• 17 van Vollenhoven RF, Bertsias G, Doria A. et al. 2021 DORIS definition of remission in SLE: final recommendations from an international task force. Lupus Sci Med 2021; 8 (01) x