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Upfront: Stopping the stocking?

28 November, 2014

Upfront: Stopping the stocking?

With mixed evidence on the efficacy of compression stockings, Naomi Carlisle argues that it may be time to abandon their use.

Thromboembolism, which had been the largest cause of maternal death since 1985 in the UK, has dropped to third place in the 2011 report from the Centre for Maternal and Child Enquiries (Cantwell et al, 2011). Only 18 women died from the condition in 2006-08, a drop from 48 in 1994-96 (Cantwell et al, 2011). 

Most hospitals now assess women for risk of deep vein thrombosis (DVT) when they become an obstetric inpatient. If a woman is deemed to be high risk, then graduated compression stockings and low molecular weight heparin are usually advised. But the evidence for the efficacy of graduated compression is inconclusive, so should we still recommend them? 
NICE guidelines (2010) recommend compression stockings as a prophylactic measure in suitable women during pregnancy and postpartum. A Cochrane review also found that graduated compression stockings were effective at reducing the risk of DVTs in hospitalised patients (Sachdeva et al, 2010). But the Cochrane review did not include two large studies, the conclusions of which advised against the use of compression stockings (Whittaker et al, 2013). Cochrane failed to identify whether all the trials reviewed were free of support from stocking manufacturers that could affect reliability (Whittaker et al, 2013). Perhaps, then, NICE’s recommendations should be reviewed (Whittaker et al, 2013)?
This is supported by a study, which found that in a sample of 100 patients’ legs wearing compression stockings, pressure applied at the ankle was, on average, 13 mmHg instead of the manufacturers’ intended compression of 18 mmHg (Bowling et al, 2014). Only 14% of the stockings demonstrated an acceptable gradation of reduced pressure between the ankle and calf (Bowling et al, 2014). 
NICE and Cochrane give no preference to whether knee- or thigh-length stockings are more effective at reducing DVTs (Sajid et al, 2012; NICE, 2010). But one study found that knee-length stockings are more comfortable for patients, less expensive and have a higher compliance level (Brady et al, 2007).
This is an important consideration, as the same study found that 37.2% of patients were not compliant with wearing compression stockings (Brady et al, 2007). Perhaps, then, hospitals should use only knee-length stockings?   
Or maybe stockings should be abandoned altogether, as they are often failing to have the desired prophylactic effect and may even cause harm (Bowling et al, 2014)?
Even if patients are compliant with compression stockings, around 20% of stockings are worn incorrectly and re-measurements are not happening every 24 hours, as recommended (Bowling et al, 2014). This may improve if there were standardised measuring methods for compression stockings (Nørregaard et al, 2014) or an increased overlap between sizes or open-ended sizes, to ensure a greater proportion of legs fit compression stockings correctly (Macintyre et al, 2013).
With the evidence so mixed on the benefits of compression stockings, it is clear that more research is needed. In the meantime, it is important for midwives to continue educating mothers about the prophylactic measures and the signs and symptoms of DVTs, to ensure that the maternal death rate continues its downward trend.
Possible symptoms of DVT 
► Pain, swelling and tenderness in one leg (usually the calf)
► A heavy ache in the affected area
► Warm skin in the area of the clot
► Redness of the skin, particularly at the back of the leg, below the knee
► Usually in one leg, though not always
► Increased pain when bending the foot upward towards the knee.
Naomi Carlisle
Midwife, King’s College Hospital, London
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Bowling K, Ratcliffe C, Townsend J, Kirkpatrick U. (2014) Clinical thromboembolic deterrent stockings application: are thromboembolic deterrent stockings in practice matching manufacturers application guidelines? Phlebology: The Journal of Venous Disease See: Unboundmedicine.com (accessed 18 November 2014).
Brady D, Raingruber B, Peterson J, Varnau W, Denman J, Resuello R, De Contreaus R, Mahnke J. (2007) The use of knee-length versus thigh-length compression stockings and sequential compression devices. Critical Care Nursing Quarterly 30(3): 255-62.
Centre for Maternal and Child Enquires (CMACE). (2011) Saving mothers’ lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report on the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 118(Suppl 1): 1–203.
Macintyre L, Kent K, McPhee D. (2013) Do anti-embolism stockings fit our legs? Leg survey and data analysis. International Journal of Nursing Studies 50(7): 914-23.
NICE. (2010) Venous thromboembolism: reducing the risk: Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. NICE guidelines [CG92]. See: http://www.nice.org.uk/guidance/cg92 (accessed 18 November 2014).
Nørregaard S, Bermark S, Gottrup F. (2014) Do ready-made compression stockings fit the anatomy of the venous leg ulcer patient?  Journal of Wound Care 23(3): 128-35.
Sachdeva A, Dalton M, Amaragiri SV, Lees T. (2010) Elastic compression stockings for prevention of deep vein thrombosis. Cochrane Database of Systematic Reviews 7: CD001484. 
Sajid MS, Desai M, Morris RW, Hamilton G. (2012) Knee length versus thigh length graduated compression stockings for prevention of deep vein thrombosis in postoperative surgical patients. Cochrane Database of Systematic Reviews 5: CD007162.
Whittaker L, Baglin T, Vuylsteke A. (2013) Challenging the evidence for graduated compression stockings. British Medical Journal 346: f3653.