Venous and Arterial Thrombosis during Pregnancy: Epidemiology

 

 Buy Article Permissions and Reprints

ABSTRACT

Venous thromboembolism is an important cause of maternal morbidity and mortality throughout the developed world with an incidence of about 1 per 1000 deliveries, of which 1-2% are fatal. Two thirds of women who have a pregnancy-associated deep vein thrombosis develop the post-thrombotic syndrome and suffer long-term morbidity. The risk of venous thromboembolism is greater in older women and in women who have an operative delivery. Other risk factors include obesity, high parity, and immobilization. Acquired or inherited thrombophilias augment the risk, and some women with a previous history of venous thromboembolism may be at increased risk of a recurrence associated with pregnancy. Arterial thrombosis is uncommon in pregnancy but may have devastating consequences. The incidence of ischemic stroke associated with pregnancy is unknown but is estimated to be about 0.18 per 1000 deliveries-the majority being the result of arterial occlusion. Myocardial infarction is estimated to occur in 0.1 per 1000 women in association with pregnancy. Events occur most frequently peripartum or postpartum. Risk factors include maternal age, atherosclerosis, obesity, hypertension, and smoking.

REFERENCES

• 1 Confidential Enquiries into Maternal Deaths. Why Mothers Die: Report on Confidential Enquiries into Maternal Deaths 1994-1996. London: The Stationery Office 1998
  Google Scholar
• 2 Berg C J, Atrash H K, Koonin L M. et al . Pregnancy related mortality in the United States 1987-1990.  Obstet Gynecol . 1996;  88 161-167
  CrossrefPubMedGoogle Scholar
• 3 Hogberg U, Sandstrom A. Maternal mortality in Sweden, 1980-1988.  Obstet Gynecol . 1994;  84 240-245
  PubMedGoogle Scholar
• 4 Sachs B P, Brown D A, Driscoll S G. et al . Mortality in Massachusetts. Trends and prevention.  N Engl J Med . 1987;  316 667-672
  PubMedGoogle Scholar
• 5 Hull R D, Raskob G F, Carter C J. Serial IPG in pregnancy patients with clinically suspected DVT. Clinical validity of negative findings.  Ann Intern Med . 1990;  112 663-667
  PubMedGoogle Scholar
• 6 Hull R D, Hirsh J, Carter C. et al . Diagnostic efficacy of IPG for clinically suspected DVT: a randomised trial.  Ann Intern Med . 1985;  102 21-28
  PubMedGoogle Scholar
• 7 Hull R D, Hirsh J, Sackett D. et al . Diagnostic efficacy of IPG in suspected venous thrombosis: an alternative to venography.  N Engl J Med . 1977;  296 1497-1500
  CrossrefPubMedGoogle Scholar
• 8 Lensing A WA, Prandoni P, Brandjes D. et al . Detection of DVT by real-time B-mode ultrasonography.  N Engl J Med . 1989;  320 342-345
  Google Scholar
• 9 Ginsberg J S, Kearon C, Douketis J. et al . D dimer and impedance plethysmography in patients with suspected deep vein thrombosis: results of a management trial.  Arch Intern Med . 1997;  157 1077-1081
  CrossrefPubMedGoogle Scholar
• 10 Ginsberg J S, Greer I A, Hirsh J. Use of antithrombotic agents during pregnancy.  Chest . 2001;  119 122S-131S
  CrossrefPubMedGoogle Scholar
• 11 PIOPED Investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED).  JAMA . 1990;  263 2753-2759
  Google Scholar
• 12 Hull R D, Hirsh J, Carter C. et al . Diagnostic value of ventilation-perfusion lung scanning in patients with suspected pulmonary embolism.  Chest . 1985;  88 819-828
  PubMedGoogle Scholar
• 13 Letsky E A, de Swiet M. Thromboembolism in pregnancy and its management.  Br J Haematol . 1984;  57 543-552
  PubMedGoogle Scholar
• 14 Lindqvist P, Dahlback B, Marsal K. Thrombotic risk during pregnancy: a population study.  Obstet Gynecol . 1999;  94 959-999
  PubMedGoogle Scholar
• 15 James K, Lohr J, Deshmukh R. et al . Venous thrombotic complications of pregnancy.  Cardiovasc Surg . 1996;  4 777-782
  PubMedGoogle Scholar
• 16 Kierkegaard A. Incidence and diagnosis of deep vein thrombosis associated with pregnancy.  Acta Obstet Gynecol Scand . 1983;  62 239-243
  PubMedGoogle Scholar
• 17 McColl M D, Ramsay J E, Tait R C, et al.. Risk factors for pregnancy associated venous thromboembolism.  Thromb Haemost . 1997;  78 1183-1188
  PubMedGoogle Scholar
• 18 McColl M D, Ramsay J E, Tait R C. et al . Superficial vein thrombosis incidence in association with pregnancy and prevalence of thrombophilic abnormalities.  Thromb Haemost . 1998;  79 741-742
  PubMedGoogle Scholar
• 19 Rutherford S, Montoro M, McGahe E W. et al . Thromboembolic disease associated with pregnancy: an 11 year review (Abst).  Am J Obstet Gynecol . 1991;  164(Suppl) S286
  PubMedGoogle Scholar
• 20 Macklon N S, Greer I A. Venous thromboembolic disease in obstetrics and gynaecology: the Scottish experience.  Scot Med J . 1996;  41 83-86
  PubMedGoogle Scholar
• 21 Lindhagen A, Bergqvist A, Bergqvist D. et al . Late venous function in the leg after deep vein thrombosis occurring in relation to pregnancy.  Br J Obstet Gynaecol . 1986;  93 348-352
  PubMedGoogle Scholar
• 22 Greer I A. Thrombosis in pregnancy: maternal and fetal issues.  Lancet . 1999;  353 1258-1265
  CrossrefPubMedGoogle Scholar
• 23 Lao T T, de Swiet M, Letsky E. et al . Prophylaxis of thromboembolism in pregnancy: an alternative.  Br J Obstet Gynaecol . 1985;  92 202-206
  PubMedGoogle Scholar
• 24 Badaracco M, Vessey M. Recurrence of venous thromboembolic disease and use of oral contraceptive.  Br Med J . 1974;  1 215-217
  PubMedGoogle Scholar
• 25 Brill-Edwards P, Ginsberg J S, Gent M. et al . Safety of withholding heparin in pregnant women with a history of venous thromboembolism.  N Engl J Med . 2000;  343 1439-1444
  CrossrefPubMedGoogle Scholar
• 26 Simioni P, Tormene D, Prandoni P. et al . Pregnancy related recurrent events in thrombophilic women with a previous venous thromboembolism [letter].  Thromb Haemost . 2001;  86 929
  PubMedGoogle Scholar
• 27 McColl M D, Ellison J, Greer I A. et al . Prevalence of the post-thrombotic syndrome in young women with previous venous thromboembolism.  Br J Haematol . 2000;  108 272-274
  CrossrefPubMedGoogle Scholar
• 28 McFaul P B, Dornan J C, Lamki H. et al . Pregnancy complicated by maternal heart disease. A review of 519 women.  Br J Obstet Gynaecol . 1988;  95 861-867
  PubMedGoogle Scholar
• 29 Cannegieter S, Rosendaal F R, Briet E. Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses.  Circulation . 1994;  89 635-641
  CrossrefPubMedGoogle Scholar
• 30 Hanania G, Thomas D, Michel P L. et al . Pregnancy and prosthetic heart valves; a French co-operative retrospective study of 155 cases.  Eur Heart J . 1994;  15 1651-1658
  PubMedGoogle Scholar
• 31 Chan W S, Anand S, Ginsberg J S. Anticoagulation of pregnant women with mechanical heart valves.  Arch Intern Med . 2000;  160 191-196
  CrossrefPubMedGoogle Scholar
• 32 Sullivan J M, Ramanathan K B. Management of medical problems in pregnancy-severe cardiac disease.  N Engl J Med . 1985;  313 304-309
  PubMedGoogle Scholar
• 33 Hankins G D, Wendel G D, Leveno K J. et al . Myocardial infarction during pregnancy. A review.  Obstet Gynecol . 1985;  65 139-146
  PubMedGoogle Scholar
• 34 Roth A, Elkayam U. Acute myocardial infarction associated with pregnancy.  Ann Intern Med . 1996;  125 751-762
  PubMedGoogle Scholar
• 35 Liao J, Cockrill B, Yurchak P. Acute myocardial infarction after ergonovine administration for uterine bleeding.  Am J Cardiol . 1991;  68 823-824
  CrossrefPubMedGoogle Scholar
• 36 Taylor G B, Cohen B. Ergonovine induced coronary artery spasm and myocardial infarction after normal delivery.  Obstet Gynecol . 1985;  66 821-822
  PubMedGoogle Scholar
• 37 Pettiti D B, Sidney S, Quesenberry C P. et al . Incidence of stroke and myocardial infarction in women of reproductive age.  Stroke . 1997;  28 280-283
  PubMedGoogle Scholar
• 38 Jaigobin C, Silver F. Stroke and pregnancy.  Stroke . 2000;  31 2948-2951
  CrossrefPubMedGoogle Scholar
• 39 Kittner S J, Stern B J, Feeser B R. et al . Pregnancy and the risk of stroke.  N Engl J Med . 1996;  335 768-774
  CrossrefPubMedGoogle Scholar
• 40 Cross J, Castro P, Jennett W B. Cerebral strokes associated with pregnancy and the puerperium.  Br Med J . 1968;  3 214-218
  PubMedGoogle Scholar
• 41 Simolke G A, Cox S M, Cunningham F G. Cerebrovascular accidents complicating pregnancy and the puerperium.  Obstet Gynecol . 1991;  78 37-42
  PubMedGoogle Scholar
• 42 Hagen P T, Scholz D G, Edwards W D. Incidence and size of patent foramen ovale during the first 10 decades of life; an autopsy study of 965 normal hearts.  Mayo Clinic Proc . 1984;  59 17-20
  CrossrefPubMedGoogle Scholar
• 43 Clark P, Brennand J, Conkie J A. et al . Activated protein C sensitivity, protein C, protein S and coagulation in normal pregnancy.  Thromb Haemost . 1998;  79 1166-1170
  PubMedGoogle Scholar
• 44 Kutteh W H. Antiphospholipid antibodies and reproduction.  J Reprod Immunol . 1997;  35 151-171
  PubMedGoogle Scholar
• 45 Branch D W, Silver R M, Blackwell J L. et al . Outcome of treated pregnancies with antiphospholipid syndrome. An update of the Utah experience.  Obstet Gynecol . 1992;  80 614-620
  PubMedGoogle Scholar
• 46 Thorp J M, Chescheir N C, Fann B. Postpartum myocardial infarction in a patient with antiphospholipid syndrome.  Am J Perinatol . 1994;  11 1-3
  PubMedGoogle Scholar
• 47 Conard J, Horellou M H, van Dreden P. et al . Thrombosis and pregnancy in congenital deficiencies in antithrombin III, protein C or protein S: study of 78 women.  Thromb Haemost . 1990;  63 319-320
  PubMedGoogle Scholar
• 48 Pabinger I, Schneider B. Thrombotic risk in hereditary antithrombin III, protein C, or protein S deficiency. Gesellschaft fur Thrombose- und Hamostaseforschung (GTH) Study Group on Natural Inhibitors.  Arterioscler Thromb Vasc Biol . 1996;  16 742-748
  CrossrefPubMedGoogle Scholar
• 49 Hellgren M, Svensson P, Dahlback B. Resistance to activated protein C is a basis for venous thromboembolism associated with pregnancy and oral contraceptives.  Am J Obstet Gynecol . 1995;  173 210-213
  CrossrefPubMedGoogle Scholar
• 50 Hollander J E, Hoffmann R S, Gennis P, et al., Prospective multicenter evaluation of cocaine-associated chest p ain. <~>Cocaine Associated Chest Pain (COCHPA) Study Group.  Acad Emerg Med . 1994;  1 330-339
  PubMedGoogle Scholar
• 51 Liu S, Forrester R M, Murphy G S. et al . Anaesthetic management of a parturient with myocardial infarction related to cocaine use.  Can J Anaesth . 1992;  39 858-861
  PubMedGoogle Scholar
• 52 Livingston J, Mabie B, Ramanathan J. Crack cocaine, myocardial infarction, and troponin I levels at the time of caesarean delivery.  Anesth Analg . 2000;  91 913-915
  PubMedGoogle Scholar
• 53 Foster K, Lader D, Cheeseborough S. Infant Feeding Survey 1995. London: The Stationery Office 1997
  Google Scholar
• 54 Prescott-Clarke P, Primatesta P. Health Survey for England 1996. London: The Stationery Office 1998
  Google Scholar
• 55 NHS Maternity Statistics, England: 1989-1990 and 1994-1995. Department of Health Statistical Bulletin, December 1997. 
  Google Scholar