Venous thromboembolism (VTE) risk during gynecologic noncancer surgery varies between procedures and patients, according to a recent study published in the American Journal of Obstetrics & Gynecology.
Takeaways
- The study highlights significant variations in venous thromboembolism (VTE) and major bleeding risks across different gynecologic noncancer surgeries, emphasizing the importance of tailored approaches to thromboprophylaxis.
- With approximately 450,000 hysterectomies annually in the United States, there's a substantial need for understanding and managing associated risks, including VTE and major bleeding.
- The findings underscore the necessity of balancing VTE and bleeding risks, particularly regarding pharmacologic thromboprophylaxis, where the potential benefits must be carefully weighed against the risks of adverse bleeding events.
- The absence of procedure-specific guidance on thromboprophylaxis in existing guidelines highlights a gap in addressing the nuanced risk profiles across various gynecologic noncancer surgeries.
- Clinicians should consider patient-specific factors and the nature of the surgical procedure when determining thromboprophylaxis strategies, aiming to mitigate VTE risk while minimizing the likelihood of significant bleeding complications.
Approximately 450,000 hysterectomies occur in the United States annually, indicating a high rate of noncancer gynecologic surgeries. Despite improvements in safety during these procedures, there are associated risks including VTE and major bleeding. These complications may cause transfusion, reintervention, or death.
VTE risk can be reduced by pharmacologic thromboprophylaxis, but this method is also associated with increased risk of bleeding. This indicates a need to balance VTE and bleeding risks, with decisions made based on baseline risks. However, patient- and procedure-specific guidance on thromboprophylaxis is not provided in guidelines.
To estimate procedure-specific risk estimates of symptomatic VTE and major bleeding during gynecologic noncancer surgery, investigators conducted a systematic review. Observational studies with 50 or more participants receiving gynecologic noncancer surgeries and reporting risk estimates for at least 1 outcome of interest were included in the analysis.
Outcomes of interested included fatal pulmonary embolism (PE), symptomatic PE, symptomatic deep vein thrombosis, symptomatic VTE, symptomatic splanchnic vein thrombosis, fatal bleeding, bleeding requiring reintervention, bleeding leading to transfusion, and bleeding leading to hemoglobin level below 70 g/L.
Literature was found through searches of the MEDLINE, Embase, Google Scholar, and Web of Science databases between January 1, 2000, and November 25, 2020. Eligibility and risk of bias was evaluated by pairs of independent reviewers.
Risk of bias was determined based on study population sampling, thromboprophylaxis reporting, information source, recruitment years, specification of follow-up duration, and study type.
The cumulative incidence of symptomatic VTE and major bleeding within 28 days was the primary outcome of the analysis. Bleeding definitions included bleeding requiring intervention, bleeding leading to transfusion of red blood cells, and bleeding leading to postoperative hemoglobin level under 70 g/L.
There were 131 studies that met eligibility criteria, and 19 had authors provide additional information. Patients were aged a mean or median 37 years during myomectomy, 24 years during adnexal torsion management, 59 years during sacrocolpopexy, and 49 years during total hysterectomy.
Low risk of bias was reported in 9% of studies, moderate risk in 22%, and high risk in 69% Patients with no VTE risk factor were defined a low risk, those with 1 factor as medium risk, and those with 2 or more factors or personal VTE history as high risk.
Of studies that reported the use and duration of pharmacologic thromboprophylaxis, a median 0 days was reported following vaginal sling surgery for incontinence, surgical abortion, and uterine artery embolization. A median duration of 3 days was reported following vaginal pelvic organ prolapse surgery with hysterectomy and vaginal total hysterectomy.
The median duration was 4 days following open hysterectomy, 10 days following minimally invasive deep endometriosis surgery, and 21 days following minimally invasive sacrocolpopexy. Mechanical prophylaxis use was reported by 11% of studies.
Variations in symptomatic VTE and major bleeding risks at 4 weeks postsurgery were found between procedures and patient populations. The lowest median symptomatic VTE risk was under 0.1% for transvaginal oocyte retrieval and vaginal sling surgery for urinary incontinence, while the highest was 1.5% for minimally invasive sacrocolpopexy with hysterectomy.
A risk of VTE under 0.5% was reported for 60% of procedures, 0.5% to 1% for 20%, and 1% to 1.5% for 20%. For bleeding requiring reintervention, the median risk was lowest at under 0.1% for uterine artery embolization and transvaginal oocyte retrieval, vs the highest rate of 4% for open myomectomy.
The risk of bleeding leading to transfusion ranged from under 0.1% for minimally invasive salpingo-oophorectomy to 14.1% for open myomectomy. A risk below 0.5% was reported for 23% of procedures, 0.5% to 1% for 32%, and over 1% for 45%.
The risk of VTE was greater than the risk of bleeding causing transfusion for 19% of procedures. For bleeding leading to hemoglobin levels under 70 g/L, most procedures had a risk below 0.1%.
These results indicated mostly low risks of VTE following noncancer gynecologic surgeries. Investigators concluded the risks of pharmacologic thromboprophylaxis may often outweigh potential benefits.
Reference
Lavikainen LI, Guyatt GH, Kalliala IEJ, et al. Risk of thrombosis and bleeding in gynecologic noncancer surgery: systematic review and meta-analysis. American Journal of Obstetrics & Gynecology. 230(4):390-402. doi:10.1016/j.ajog.2023.11.1255
