188 - Measures to Reduce Peri- and Intra-Operative Blood Loss at Myomectomy: a Survey of Obstetrician-Gynecologists

Abstract

Study Objective: To determine current measures used by Canadian obstetrician-gynecologists (Ob/Gyns) to optimize patients undergoing myomectomy during the peri- and intra-operative periods, and to identify gaps in knowledge or barriers to access of blood conservation methods. Design: Survey. Setting: Full- or community- academic affiliated hospital. Patients: Patients undergoing myomectomies for benign disease performed by Canadian obstetrician gynecologists. Intervention: A self-administered electronic questionnaire was distributed to Canadian Ob/Gyns from September through December 2016. Measurements and Main Results: 68/120 (57%) completed responses were analyzed. Most respondents were general Ob/Gyn [72.1% (49) Ob/Gyn, 20.6% (14) Ob/Gyn-MIS, 4.4 % (3) MIS, 2.9% (2) GYN], who worked in the community [70.6% (48)] and practiced >10 years [67.7% (46)]. 79.4% (54) delay surgery to correct anemia. Most common preoperative medical agents used were: Tranexamic acid (94.1%), Ulipristal acetate (92.6%), GnRH agonist (79.4%), and Combined hormonal contraception (58.8%). Majority had access to hematology [83.8% (57)] and to IV iron [98.5% (67)], and have previously ordered IV iron before [82.4% (56)]. However, respondents had variable knowledge of oral and IV iron dosing and administration. Most common intra-operative agents used were: 94.1% (64) Vasopressin [subserosal (SS) 59.4% vs. intra-myometrial (IMM) 40.6%], 26.6% (17) Vasopressin with Epinephrine (SS 58.8% vs. IMM 41.2%), 73.5% (50) IV Tranexamic acid, 66.2% (45) Mechanical tourniquet, 33.8% (23) Misoprostol, 22.1% (15) Uterine artery ligation, 17.6% (12) Topical sealant, and 11.8% (8) Intra-op blood salvage. 52.9% (36) estimated 250–499 mL blood loss, <10% personal transfusion rate [73.5% (50)], but 69.1% (47) were uncertain of institutional transfusion rate. Conclusion: Most gynecologists delay surgery to correct anemia, but are uncertain of institutional transfusion rate, iron dosing and administration, and optimal peri-/intra-operative multi-modal approach for blood loss conservation. Education and creation of a clinical pathway to address uncertainty in measures to reduce bleeding can lead to decreased perioperative morbidity for myomectomy patients.