Myomectomy associated blood transfusion risk and morbidity after surgery

Women who receive blood transfusions with myomectomy have increased risk of experiencing major com- plications within 30 days of surgery.

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Volume 114, Issue 1, Pages 175–184

Authors:

Tana Kim, M.D., Mackenzie P. Purdy, M.D., Lauren Kendall-Rauchfuss, M.D., Elizabeth B. Habermann, Ph.D., Katherine A. Bews, B.A., Amy E. Glasgow, M.H.A., Zaraq Khan, M.B.B.S.

Abstract:

Objective

To evaluate blood transfusion risks and the associated 30-day postoperative morbidity after myomectomy.

Design

Retrospective cohort study.

Setting

Not applicable.

Patient(s)

Women who underwent myomectomies for symptomatic uterine fibroids (N = 3,407).

Intervention(s)

Blood transfusion during or within 72 hours after myomectomy.

Main Outcome Measure(s)

The primary outcomes were rate of blood transfusion with myomectomy and risk factors associated with receiving a transfusion. The secondary outcome was 30-day morbidity after myomectomy.

Result(s)

The overall rate of blood transfusion was 10% (hysteroscopy, 6.7%; laparoscopy, 2.7%; open/abdominal procedures, 16.4%). Independent risk factors for transfusion included as follows: black race (adjusted odds ratio [aOR] 2.27, 95% confidence interval [CI] 1.62–3.17) and other race (aOR 1.77, 95% CI 1.20–2.63) compared with white race; preoperative hematocrit <30% compared to ≥30% (aOR 6.41, 95% CI 4.45–9.23); preoperative blood transfusion (aOR 2.81, 95% CI 1.46–5.40); high fibroid burden (aOR 1.91, 95% CI 1.45–2.51); prolonged surgical time (fourth quartile vs. first quartile aOR 11.55, 95% CI 7.05–18.93); and open/abdominal approach (open/abdominal vs. laparoscopic aOR 9.06, 95% CI 6.10–13.47). Even after adjusting for confounders, women who required blood transfusions had an approximately threefold increased risk for experiencing a major postoperative complication (aOR 2.69, 95% CI 1.58–4.57).

Conclusion(s)

Analysis of a large multicenter database suggests that the overall risk of blood transfusion with myomectomy is 10% and is associated with an increased 30-day postoperative morbidity. Preoperative screening of women at high risk for transfusion is prudent as perioperative transfusion itself leads to increased major postoperative complications.

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1 Comments

Go to the profile of william  parker
william parker 13 days ago

To the Authors,


The data presented by Kim et al in their interesting article on blood loss and open abdominal myomectomy highlights several issues about the performance of these procedures.  


As noted in the paper, myomectomy has become a preferred procedure by many women with symptomatic fibroids, including those with fertility concerns and others who have a desire for uterine preservation for its own sake.  Current evidence also suggests that hysterectomy with ovarian conservation can decrease ovarian hormone production, lead to earlier onset of menopause and be associated with deleterious metabolic and cardiovascular effects.  (YYY) These data further support myomectomy as an excellent technique to relieve the symptomatology associated with fibroids.


As the authors state, large databases that rely on ICD or CPT codes for data collection are fraught with erroneous data, as high as 41% when charts are reviewed.(Grimes) Point in fact, the study authors were unable to validate ICD codes via chart review and needed to exclude approximately 12,000 surgeries. Also missing is information that could help us better interpret these data; such as whether surgeons employed strategies to increase pre-operative hemoglobin levels or decrease intraoperative blood loss. 


Intravenous iron infusions, given 3 times a week for 3 weeks, has been shown to increase preoperative hemoglobin levels by up to 3.0 g/dL. (Kim)  A Cochrane review found significant reductions in blood loss during myomectomy with: vaginal misoprostol (-98 ml); intra-myometrial vasopressin (-246 ml); intravenous tranexamic acid (-243 ml); and a polyglactin suture placed around both the cervix and infundibulo-pelvic ligaments (-1870 ml). (Kongnyuy)  In a study the authors cited, only 6.4% of 393 patients required transfusions when a tourniquet and vasopressin were used during open abdominal myomectomy.


Furthermore, there is no information regarding criteria for blood transfusions during the myomectomies studied. Increasing awareness of the morbidity associated with transfusion, as noted in this study, has  led many institutions to tolerate hemoglobin values to 7 g/dL before a blood transfusion is considered (previous cutoff  levels were less than 10 g/dL). And, recent advances in enhanced recovery after surgery (ERAS) has led anesthesiologists to abandon the treatise of hypervolemia in surgical patients.  ERAS protocols recommend euvolemia to prevent fluid overload and bowel edema, but it also eliminates the possibility that hemoglobin levels will be artificially lower due to dilution, which can trigger unnecessary transfusions.  


Lastly, we are unable to ascertain the level of expertise for the surgeons completing these cases, since we know better trained surgeons have fewer complications. Interestingly, there are not now, nor have there ever been, requirements for Obstetrics and Gynecology residents to learn how to correctly perform myomectomies during their training.  The minimum required number of hysterectomies performed for a graduating resident is 85. The Accreditation Council for Graduate Medical Education (ACGME) requirement for open-abdominal plus laparoscopic myomectomy is 0.   The authors of this study suggest that referral to minimally invasive surgeons might improve outcomes with laparoscopic myomectomies.  Our group also believes that women requesting/requiring open myomectomies should likewise be referred to gynecologists who are experienced in these procedures until sufficient training is commonplace.  

 
We understand the difficulties in solving clinical queries for many procedures performed by gynecologists. We also believe it is time to rely less on administrative databases, as they are fraught with inaccuracies and errors. Prospective data collection using predetermined criteria are the best way possible, outside of a randomized controlled trial, to answer these questions. We also see a glaring omission in the education of our young Obstetrics and Gynecology physicians. As we continue to discover new means to improve women’s health care, we need to adapt our skill sets to meet the needs of our patients.  We fully support the modification of surgical requirements for resident physicians with regards to myomectomy training.  

William Parker, MD
UC San Diego School of Medicine

Elizabeth Pritts
Wisconsin Fertility Institute

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Grimes D. Epidemiologic research with administrative databases: red herrings, false alarms and pseudo-epidemics Hum Reprod 2015,  30(8): 1749–52.


Kim YH, Chung HH, Kang SB, Kim SC, Kim YT. Safety and usefulness of intravenous iron sucrose in the management of preoperative anemia in patients with menorrhagia: a phase IV, open-label, prospective, randomized study. Acta Haematol. 2009;121:37-41. 


Kongnyuy EJ, Wiysonge CS. Interventions to reduce haemorrhage during myomectomy for fibroids. Cochrane Database Syst Rev. 2014 Aug 15;(8):CD005355.


Barakat EE, Bedaiwy MA, Zimberg S, Nutter B, Nosseir M, Falcone T. Robotic-assisted, laparoscopic, and abdominal myomectomy: a comparison of surgical outcomes. Obstet Gynecol. 2011;117:256-265.