General Internal Medicine, Department of Internal Medicine, Geneva University Hospital and Faculty of Medicine, 24 rue Micheli-du-Crest, CH-1211 Geneva 14, Switzerland.
Thromb Haemost. 2010 Jan;103(1):129-37. doi: 10.1160/TH09-06-0349. Epub 2009 Oct 26.
Although venous thromboembolism (VTE) is the leading cause of maternal mortality in developed countries, the usefulness of preventive low-molecular-weight heparin (LMWH) after cesarean delivery remains a matter of controversy. It was the objective of this study to evaluate the usefulness of thromboprophylaxis with LMWH after cesarean delivery. A decision model was constructed to evaluate the risks and benefits associated with a seven-day LMWH prophylaxis, compared with none. All probabilities were obtained from literature according to the highest level of evidence. We performed our analysis on two different sets of outcomes (utilities and disutilities), to calculate the quality-adjusted life expectancy at three months. Finally, we calculated the outcomes for four hypothetical cases with different risk. Prophylaxis with LMWH yielded the highest quality-adjusted life expectancy, with a net gain of 1.5-2.8 quality-adjusted days. Sensitivity analyses showed the incidence of VTE after cesarean delivery and the haemorrhagic risk related to LMWH to be critical, at threshold values of 0.15-0.22% and 0.23-0.35%, respectively. In the hypothetical cases, LMWH was safe but only marginally more effective in women with no risk factors. In case of an emergency procedure, a body-mass index >25kg/m(2), tobacco smoking, or any combination of these, reductions in VTE greatly outnumbered the increase in major haemorrhages, with a modest benefit on mortality. Our decision analysis suggests that the benefits of LMWH after cesarean delivery exceed the risks. This benefit is, however, very low in women with no risk factors.
虽然静脉血栓栓塞症（VTE）是发达国家产妇死亡的主要原因，但剖宫产术后预防性使用低分子肝素（LMWH）的效果仍存在争议。本研究旨在评估剖宫产术后 LMWH 预防性应用的效果。建立决策模型来评估与无 LMWH 预防性应用相比，LMWH 预防性应用 7 天的风险和获益。所有概率均根据最高证据水平从文献中获得。我们对两种不同的结果（效用和不效用）进行了分析，以计算三个月时的质量调整生命预期。最后，我们计算了具有不同风险的四个假设病例的结果。LMWH 预防性应用可获得最高的质量调整生命预期，净获益为 1.5-2.8 个质量调整生命日。敏感性分析显示，剖宫产术后 VTE 的发生率和与 LMWH 相关的出血风险为关键因素，阈值分别为 0.15-0.22%和 0.23-0.35%。在假设病例中，LMWH 是安全的，但在无危险因素的女性中，效果仅略有改善。对于紧急手术、体重指数（BMI）>25kg/m2、吸烟或这些因素的任意组合，VTE 的减少数量大大超过大出血的增加数量，死亡率适度降低。我们的决策分析表明，剖宫产术后 LMWH 的获益超过风险。然而，在无危险因素的女性中，这种获益非常低。
