Prevention and Treatment of Thrombo-embolic Disease in Gynaecological Surgery

Abstract

Objective: to identify pre-operative risk factors for venous thrombo-embolism (VTE) and to provide guidelines for risk assessment and for thrombo-prophylactic measures for VTE in women undergoing gynaecological surgery. Guidelines for diagnostic testing and for acute and long-term treatment of VTE are also provided.Options: low, moderate and high-risk groups of patients are defined and appropriate prophylactic measures are outlined. Alternative measures to low-dose unfractionated heparin (LDUH), for example low molecular weight heparin (LMWH), leg stockings, dextran 70 and acetylsalicylic acid are discussed. Alternative methods for acute treatment of VTE are also provided.Outcomes: venous thrombo-embolism remains a major cause of morbidity and mortality following gynaecological surgery. Adequate prophylaxis can decrease the incidence of VTE.Evidence: evidence was gathered using MEDLINE (National Library of Medicine) to identify pertinent studies and from bibliographies of articles thus identified.Recommendations: prophylactic measures for VTE decrease its incidence (Level 1 evidence). Based on risk assessment, more patients should be considered for prophylaxis (Grade A recommendation). The occurrence of VTE is effectively reduced by the use of LDUH and maybe more soby the use of LMWH (Level 1 evidence). For treatment of VTE, unfractionated heparin (UH) has been standard, although LMWH has now been proven to be at least as effective and safe (Level 1 evidence). Based on this evidence, LDUH or LMWH should be used in prophylaxis when feasible and UH or LMWH in treatment of VTE (Grade A recommendation). Following initial heparinization for treatment of VTE, patients should receive oral anticoagulation for at least three months (Grade A recommendation). Consideration could be given to extending prophylaxis beyond hospital discharge in high-risk patients.