Women's values and preferences and health state valuations for thromboprophylaxis during pregnancy: A cross-sectional interview study

- Pregnant women with prior venous thromboembolism (VTE) are at risk of recurrence.
- The net benefit of antepartum LMWH in this setting is uncertain.
- Pregnant women values and preferences for antepartum LMWH prophylaxis are unknown.
- Most women with prior VTE choose antepartum LMWH; an important minority will not.
- Shared decisions about the use of antepartum LMWH prophylaxis should be emphasized.

BackgroundPregnant women with prior venous thromboembolism (VTE) are at risk of recurrence. Prophylaxis with low molecular weight heparin (LWMH) reduces that risk but is inconvenient, costly, and may be associated with increased risks of obstetrical bleeding. The views of pregnant women, crucial when making prophylaxis recommendations, are currently unknown.MethodsCross-sectional international multicenter study. We included women with a history of VTE who were either pregnant or planning pregnancy. We provided information regarding risk of VTE recurrence with and without LMWH and determined participant's willingness to receive LMWH prophylaxis through direct choice exercises, preference-elicitation (utilities) for health states (e.g. burden of LMWH prophylaxis), and a probability trade-off exercise.ResultsOf 123 women, more women at high risk than those at low risk of recurrence (86.4% vs. 60.0%; p = 0.003) chose to use LMWH. The median threshold reduction in VTE at which women were willing to accept use of LMWH, given a 16% risk of VTE without prophylaxis, was 3% (interquartile range: 1 to 6). Participants' evaluation of the relevant health states varied widely and was unrelated to their direct choices to use or not use LMWH.ConclusionsAlthough the majority of women with a previous VTE, pregnant or planning pregnancy choose to take LMWH during pregnancy, a minority -and in low risk women, a large minority- do not. Our results highlight the need for individualized shared decision-making (SDM) in the clinical encounter, and for guideline panels to make weak recommendations in favor of LMWH that make clear the need for SDM.