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Thromb Haemost 2008; 100(02): 246-252
DOI: 10.1160/TH08-04-0238
Blood Coagulation, Fibrinolysis and Cellular Haemostasis
Schattauer GmbH

Recurrent venous thromboembolism after pregnancy-associated versus unprovoked thromboembolism

Richard H.White
1   Department of Internal Medicine
,
Wee-Shian Chan
3   Department of Medicine, University of Toronto, Toronto, Ontario, Canada
,
Hong Zhou
2   Department of Medicine and Statistics, UC Davis, Sacramento, California, USA
,
Jeffrey S. Ginsberg
4   Department of Medicine, McMaster University, Hamilton, Ontario, Canada
› Author AffiliationsFinancial support: Funded by the Hibbard E. Williams Endowment UC Davis School of Medicine, Sacramento, California, USA.
Further Information

Publication History

Received 17 April 2008

Accepted after minor revision 29 May 2008

Publication Date:
22 November 2017 (online)

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Summary

It is not known whether women who develop venous throm-boembolism (VTE) during pregnancy have a higher or lower incidence of recurrent VTE than women with unprovokedVTE. The aim of the study was to compare the risk of recurrent VTE among women with pregnancy-associated VTE to women with unprovoked VTE. Hospital discharge data identified women age 18–46 years old with pregnancy-associated or unprovoked index VTE between 1994 and 2005. Risk of recurrent VTE was compared between six and 60 months after the index event using both age-matched comparison of disease-free survival and proportional hazard modelling, adjusting for age and other risk factors. The Kaplan-Meier incidence of recurrent VTE in 1085 women with pregnancy-associatedVTE was 5.8% versus 10.4% in 7625 women with unprovoked VTE (p=0.02). Twelve of 34 (35%) recurrent events in the pregnancy-associated group occurred during a subsequent pregnancy compared with 29 of 331 (8.7%) events in the unprovoked group (p<0.001).In the risk-adjusted multivariate model, women with pregnancy-associated VTE had a significantly lower risk of recurrent VTE (HR = 0.6, 95%CI=0.4–0.9). Overall, the incidence of recurrentVTE during subsequent pregnancies was higher in the pregnancy group, 21 of 465 (4.5%), than in the unprovoked group, 37 of 1353 (2.7%, RR=1.7, CI:1.0–2.8). Compared to women with unprovoked VTE, women with pregnancy-associated VTE had a significantly lower long-term risk of recurrent VTE but a higher risk of recurrent VTE during a subsequent pregnancy. These findings should be considered when decisions are made about VTE prophylaxis in women with a history of pregnancy-associated VTE.

Keywords

Venous thromboembolism - epidemiology - recurrent - pregnancy - unprovoked
 

  • References

  • 1 Research Committee of, the British, Thoracic Society. Optimum duration of anticoagulation for deepvein thrombosis and pulmonary embolism. Lancet 1992; 340: 873-876.
    PubMedGoogle Scholar
  • 2 Hansson PO, Sörbo J, Eriksson H. Recurrent venous thromboembolism after deep vein thrombosis: incidence and risk factors. Arch Intern Med 2000; 160: 769-774.
    CrossrefPubMedGoogle Scholar
  • 3 Prandoni P, Lensing AW, Cogo A. et al. The long-term clinical course of acute deep venous thrombosis. Ann Intern Med 1996; 125: 1-7.
    CrossrefPubMedGoogle Scholar
  • 4 Schulman S, Rhedin AS, Lindmarker P. et al. A comparison of six weeks with six months of oral anticoagulant therapy after a first episode of venous throm-boembolism. Duration of Anticoagulation Trial Study Group. N Engl J Med 1995; 332: 1661-1665.
    CrossrefPubMedGoogle Scholar
  • 5 Levine MN, Hirsh J, Gent M. et al. Optimal duration of oral anticoagulant therapy: a randomized trial comparing four weeks with three months of warfarin in patients with proximal deep vein thrombosis. Thromb Haemost 1995; 74: 606-611.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 6 Baglin T, Luddington R, Brown K. et al. Incidence of recurrent venous thromboembolism in relation to clinical and thrombophilic risk factors: prospective cohort study. Lancet 2003; 362: 523-526.
    CrossrefPubMedGoogle Scholar
  • 7 Palareti G, Cosmi B. Predicting the risk of recurrence of venous thromboembolism. Current opinion in hematology 2004; 11: 192-197.
    PubMedGoogle Scholar
  • 8 Keeling D. Duration of anticoagulation: decision making based on absolute risk. Blood Rev. 2005 Nov 3..
    PubMedGoogle Scholar
  • 9 Schulman S, Ogren M. New concepts in optimal management of anticoagulant therapy for extended treatment of venous thromboembolism. Thromb Hae-most 2006; Sep; 96: 258-266.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 10 Bates SM, Greer IA, Hirsh J. et al. Use of anti-thrombotic agents during pregnancy: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126 (Suppl. 03) 627S-44S.
    CrossrefPubMedGoogle Scholar
  • 11 Ginsberg JS, Turpie AG. Thromboembolism and pregnancy. Int Angiol 2001; 20: 103-109.
    PubMedGoogle Scholar
  • 12 Greer IA. Venous thromboembolism and anticoagulant therapy in pregnancy. Gend Med 2005; 02 Suppl A: S10-17.
    CrossrefPubMedGoogle Scholar
  • 13 Pabinger I, Grafenhofer H. Thrombosis during pregnancy: risk factors, diagnosis and treatment. Pathophysiol Haemost Thromb 2002; 32: 322-324.
    CrossrefPubMedGoogle Scholar
  • 14 White RH, Zhou H, Murin S. et al. Effect of ethnicity and gender on the incidence of venous thromboem-bolism in a diverse population in California in 1996. Thromb Haemost 2005; 93: 298-305.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 15 White RH, Romano PS, Zhou H. et al. Incidence and time course of thromboembolic outcomes following total hip or knee arthroplasty. Arch Intern Med 1998; 158: 1525-1531.
    CrossrefPubMedGoogle Scholar
  • 16 White RH, Brickner LA, Scannell KA. ICD-9-CM codes poorly indentified venous thromboembolism during pregnancy. J Clin Epidemiol 2004; 57: 985-988.
    CrossrefPubMedGoogle Scholar
  • 17 American Hospital Association. Coding Clinic for ICD-9-CM. 2001 Quarter 01: 11-12.
    PubMedGoogle Scholar
  • 18 Health Care Utilization Project. Comorbidity Software, Version 3.1. 2005 [updated 2005 Fiscal Year 2006; cited April 17, 2006]; Available at: http://www.hcup-us.ahrq.gov/toolssoftware/comorbidity/comorbidity.jsp
    PubMedGoogle Scholar
  • 19 Stukenborg GJ, Wagner DP, Connors Jr AF. Comparison of the performance of two comorbidity measures, with and without information from prior hospitalizations. Med Care 2001; 39: 727-739.
    CrossrefPubMedGoogle Scholar
  • 20 Kearon C. Long-term management of patients after venous thromboembolism. Circulation 2004; 110 (Suppl. 09) I10-8.
    CrossrefPubMedGoogle Scholar
  • 21 Heit JA, Mohr DN, Silverstein MD. et al. Predictors of recurrence after deep vein thrombosis and pulmonary embolism: a population-based cohort study. Arch Int Med 2000; 160: 761-768.
    CrossrefPubMedGoogle Scholar
  • 22 De Stefano V, Martinelli I, Rossi E. et al. The risk of recurrent venous thromboembolism in pregnancy and puerperium without antithrombotic prophylaxis. B J Haematol 2006; 135: 386-391.
    CrossrefPubMedGoogle Scholar
  • 23 Ray JG, Chan WS. Deep vein thrombosis during pregnancy and the puerperium: a meta-analysis of the period of risk and the leg of presentation. Obstet Gynecol Surv 1999; 54: 265-271.
    CrossrefPubMedGoogle Scholar
  • 24 Buller HR, Agnelli G, Hull RD. et al. Antithrombotic Therapy for Venous Thromboembolic Disease: The Seventh ACCP Conference onAntithrombotic and Thrombolytic Therapy. Chest 2004; 126 (Suppl. 03) 401S-28.
    CrossrefPubMedGoogle Scholar
  • 25 Prandoni P, Noventa F, Ghirarduzzi A. et al. The risk of recurrent venous thromboembolism after discontinuing anticoagulation in patients with acute proximal deep vein thrombosis or pulmonary embolism A prospective cohort study in 1,626 patients. Haematologica 2007; 92: 199-205.
    CrossrefPubMedGoogle Scholar