Venous thromboembolism prophylaxis in gynecologic surgery: a systematic review.
OBJECTIVE
To comprehensively review and critically assess the available gynecologic surgery venous thromboembolism prophylaxis literature and provide clinical practice guidelines.


METHODS
MEDLINE and Cochrane databases from inception to July 2010. We included randomized controlled trials in gynecologic surgery populations. Interventions and comparators included graduated compression stockings, intermittent pneumatic compression, unfractionated heparin, and low molecular weight heparin; placebo and routine postoperative care were allowed as comparators.


METHODS
One thousand two hundred sixty-six articles were screened, and 14 randomized controlled trials (five benign gynecologic, nine gynecologic oncology) met eligibility criteria. In addition, nine prospective or retrospective studies with at least 150 women were identified and provided data on venous thromboembolism risk stratification, gynecologic laparoscopy, and urogynecologic populations.


RESULTS
Two reviewers independently screened articles with discrepancies adjudicated by a third. Eligible randomized controlled trials were extracted for these characteristics: study, participant, surgery, intervention, comparator, and outcomes data, including venous thromboembolism incidence and bleeding complications. Studies were individually and collectively assessed for methodologic quality and strength of evidence. Overall incidence of clinical venous thromboembolism was 0-2% in the benign gynecologic population. With use of intermittent pneumatic compression for benign major procedures, venous thromboembolism incidence was less than 1%. No venous thromboembolisms were identified in prospective studies of benign laparoscopic procedures. Overall quality of evidence in the benign gynecologic literature was poor. Gynecologic-oncology randomized controlled trials reported venous thromboembolism incidence (including "silent" venous thromboembolisms) of 0-14.8% with prophylaxis and up to 34.6% without prophylaxis. Fair quality of evidence supports that unfractionated heparin and intermittent pneumatic compression are both superior to placebo or no intervention but insufficient to determine whether heparins are superior to intermittent pneumatic compression for venous thromboembolism prevention. Combining two of three risks (aged 60 years or older, cancer, or personal venous thromboembolism history) substantially elevated the risk of venous thromboembolism.


CONCLUSIONS
Intermittent pneumatic compression provides sufficient prophylaxis for the majority of gynecology patients undergoing benign surgery. Additional risk factors warrant the use of combined mechanical and pharmacologic prophylaxis.
From the University of Texas Southwestern Medical Center, Dallas, Texas; the University of New Mexico Health Sciences Center, Albuquerque, New Mexico; the University Hospitals Case Medical Center, Cleveland, Ohio; Women and Infants Hospital of Rhode Island/Brown Medical School, Providence, Rhode Island; Medical College of Wisconsin, Waukesha, Wisconsin; Hartford Hospital/University of Connecticut School of Medicine, Hartford, Connecticut; the University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Eastern Virginia Medical School, Norfolk, Virginia; and Tufts Medical Center, Boston, Massachusetts.
David D
DD
Rahn
Mamta M
MM
Mamik
Tatiana V D
TVD
Sanses
Kristen A
KA
Matteson
Sarit O
SO
Aschkenazi
Blair B
BB
Washington
Adam C
AC
Steinberg
Heidi S
HS
Harvie
James C
JC
Lukban
Katrin
K
Uhlig
Ethan M
EM
Balk
Vivian W
VW
Sung
D005260:Female; D013509:Gynecologic Surgical Procedures; D006801:Humans; D019990:Perioperative Care; D016032:Randomized Controlled Trials as Topic; D054556:Venous Thromboembolism / Q000517:prevention & control*