Female Pelvic Medicine & Reconstructive Surgery:
OB/GYN, Cleveland Clinic Foundation, Cleveland, OH
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: None.
A pulmonary embolus (PE) is a life-threatening postoperative complication. Women undergoing reconstructive pelvic and incontinence surgery typically qualify as “high” or “highest” risk for venous thromboembolism (VTE) perioperatively in published guidelines.1 However, no literature exists on the risk of deep venous thrombosis (DVT) or PE in these patients. The objective of this analysis is to determine the incidence of VTE in patients undergoing urogynecologic surgery in order to guide development of a VTE prophylaxis protocol for this population.
MATERIALS AND METHODS:
All pelvic reconstructive and incontinence procedures performed by members of the Division of Urogynecology and Reconstructive Pelvic Surgery at Cleveland Clinic (Cleveland, Ohio) between 2006 and 2008 were reviewed using the electronic medical record. Preoperative notes, operative reports, hospitalization records and clinic notes were reviewed in order to collect each patient's demographics, medical history, and surgical procedure, as well as information regarding the postoperative course. Sequential compression devices (SCD) were applied to all patients intraoperatively and postoperatively until discharge. Women receiving perioperative anticoagulation were excluded. JMP 7.0 software was used to calculate frequencies, confidence intervals, chi-square tests and t-tests.
During the study period, 1130 patients underwent pelvic reconstructive or incontinence surgery. Twenty-six patients received perioperative anticoagulation and were excluded from this analysis leaving a study population of n = 1104. The mean age was 57.2 years +/−13.3 with a mean body mass index of 28.3 +/−5.6. 88.6% of the cohort was Caucasian. The mean operating room time was 183 +/−88 minutes. A total of 40 patients (3.6%) were evaluated for suspicion of VTE postoperatively with radiographic imaging including chest CT and/or lower extremity doppler US. The most common signs and symptoms among women who received imaging include shortness of breath (72%), tachycardia (61%) and lower extremity edema/swelling (50%). DVT or PE was confirmed in three patients for an overall rate of VTE in this population of 0.3% (95%CI 0.1–0.8). One patient was diagnosed with a PE, while two were diagnosed with both a DVT and PE. Each required anticoagulation. The initial diagnosis of thrombosis or embolism was made on post-operative days one, two and 14 in these women. On bivariate analysis, neither age, ethnicity, BMI, Charlson comorbidity score, active malignancy, operating room time, length of hospitalization, decreased mobility prior to surgery, hormone replacement therapy, oral contraceptive use, or central line insertion were related to risk of VTE in this study.
Conclusion: The risk of VTE in patients undergoing urogynecology surgery who receive routine prophylaxis with SCDs is 0.3%. Given this relatively low risk, the addition of prophylactic heparin therapy is unlikely to yield additional net benefit in this population in light of the potential morbidities associated with chemical prophylaxis.1
ACOG Practice Bulletin 84, August 2007