Committee Opinion No 610: Chronic Antithrombotic Therapy and Gynecologic Surgery

Outcomes in Pelvic Organ Prolapse Surgery in Women Using Chronic Antithrombotic Therapy

INTRODUCTION

Chronic antithrombotic therapy is common among patients requiring surgery for pelvic organ prolapse because of age and comorbidities. The impact of chronic anticoagulation on postoperative complications in pelvic organ prolapse surgery has not been investigated. This study aims to determine if patients on chronic antithrombotic therapy are at increased risk for postoperative complications.

METHODS

This retrospective cohort study included women having prolapse surgery from 2012 to 2015, identified by Current Procedural Terminology codes, excluding patients undergoing concomitant major nonurogynecologic procedures. Baseline characteristics were compared and all procedures performed, operative duration, estimated blood loss, and length of hospitalization. Complications (blood transfusion, intensive care unit admission, reoperation, readmission, hematoma, thromboembolic event, and infection) were compared in women on chronic antithrombotic therapy and controls. Logistic regression determined odds ratio (OR) for complications in patients on chronic antithrombotics. Complications were graded by the Clavien-Dindo classification.

RESULTS

A total of 388 charts were reviewed, and 386 patients met inclusion criteria. Twenty-one of the 386 patients were on chronic antithrombotic therapy. Chronic antithrombotic therapy increased overall complications (OR, 6.8; P < 0.0005), blood transfusion (OR, 165; P < 0.001), intensive care unit admission (OR, 19.10; P < 0.004), hospital readmission (OR, 20.7; P < 0.0005), vaginal hematoma (OR, 554.1; P < 0.001), infection (OR, 22.44; P < 0.004), and complications that required specific additional follow-up (OR, 9.42; P < 0.0005). There were no thromboembolic events. Antithrombotic therapy did not significantly increase reoperation rates (OR, 3.8; P = 0.275). Findings were maintained when adjusting for covariates of age and body mass index.

CONCLUSIONS

Postoperative surgical complications after prolapse repair procedures are increased in patients who use chronic antithrombotic medication, the majority of cases are successfully managed conservatively.

Perioperative Management of the Gynecologic Patient on Long-term Anticoagulation

The perioperative management of patients taking antithrombotic or antiplatelet medications is based on an assessment of the individual patient's risk for thrombosis or bleeding, the specific medication involved, and the nature of the planned procedure. This article describes specific strategies for whether and how these medications should be interrupted before gynecologic procedures, when they can be restarted following the procedure, and whether bridging therapy should be considered.

Management considerations for patients with uterine fibroids and concurrent venous thromboembolism

PURPOSE OF REVIEW

The purpose is to provide an update on management strategies for uterine fibroids in the setting of venous thromboembolism (VTE).

RECENT FINDINGS

Uterine fibroids and VTE are independently associated with morbidity and increasing healthcare costs. Women with large uterine fibroids have a higher likelihood of VTE. Current strategies for stratifying patients with VTE take into account the nature of the VTE (i.e., truly provoked or unprovoked) and many patients may only require short-term anticoagulation. In those patients with risk factors for recurrent VTE, longer term anticoagulation may be required.

SUMMARY

In women with large uterine fibroids, the likelihood of concurrent VTE increases. Peri and postoperative management should be determined based on patient-specific risk stratification, with the majority of patients requiring short-term anticoagulation. Further risk stratification may be required for patients with essentially an unprovoked VTE, and consultation with a thrombosis specialist is recommended.

Hysterectomy for Benign Conditions of the Uterus: Total Abdominal Hysterectomy

Hysterectomy is the most common major gynecologic procedure. Although alternatives to hysterectomy result in fewer procedures performed annually, and the use of endoscopic techniques and vaginal hysterectomy have resulted in a lower percentage performed by the open abdominal route, certain pelvic disorders require abdominal hysterectomy. Preoperative evaluation with informed consent and surgical planning are essential to select appropriate candidates. Prophylactic antibiotics, thromboprophylaxis, attention to surgical technique, and enhanced recovery protocols should be used to provide optimal outcomes.