Thrombophilia and the obstetric patient

OBJECTIVE: To examine how practicing obstetricians evaluate and manage thrombophilias in selected clinical situations. METHODS: A questionnaire investigating knowledge and practice patterns pertaining to thrombophilia was mailed to 300 randomly selected American College of Obstetricians and Gynecologists Fellows and Junior Fellows in February 2005. RESULTS: Approximately 50% (151) of questionnaires were returned. Statistical analysis focused on the 104 responding obstetricians. The majority (greater than 70%) know which thrombophilias are inherited and which are acquired. More than 50% send an inherited thrombophilia panel and antiphospholipid antibodies on patients with a history of fetal demise, intrauterine growth restriction (less than 5th percentile), abruption, and severe preeclampsia. Ninety-two percent test patients with recurrent miscarriages for antiphospholipid antibodies. Despite no clear evidence, 80% also test these patients for inherited thrombophilias. The majority intervene with either thromboprophylaxis or low-dose aspirin when managing patients at risk for thromboembolism. Seventy percent use low-molecular-weight (fractionated) heparin for patients requiring therapeutic anticoagulation, while 62% also use it for prophylactic anticoagulation. Thirty-eight percent of physicians using low-molecular-weight (fractionated) heparin monitor anti-factor Xa levels. The majority (56%) felt their residency training with regard to thrombophilia was barely adequate. Only 8% felt their training was comprehensive, while 36% felt it was adequate. CONCLUSION: Most responding obstetricians do not manage thrombophilia patients according to expert opinion. Despite the fact that often there is no clear evidence for treatment, many physicians are inclined to intervene in patients at risk for thromboembolism. Educational endeavors are needed to guide obstetricians caring for patients at risk for thromboembolism. LEVEL OF EVIDENCE: III.