Validation of a venous thromboembolism risk assessment model in gynecologic oncology

Objectives

Gynecologic oncology patients undergoing surgery are at an increased risk for venous thromboembolism (VTE). We attempted to validate a VTE risk assessment model in gynecologic oncology patients.

Methods

All gynecologic oncology patients who underwent a laparotomy for the diagnosis or suspicion of gynecologic malignancy from 2004 to 2010 were included. Demographic, surgicopathologic, and complication data were collected. VTE was based on the symptomatic diagnosis. Data for the Caprini risk assessment model (RAM) was used to score and stratify patients on their risk for VTE.

Results

1123 gynecologic oncology patients were included within this study. Ovarian cancer was the most common diagnosis (39%) with a median age of 56.1. All patients received SCDs with 40% receiving double prophylaxis. The overall incidence of VTE was 3.3%, with lower extremity deep venous thrombosis (DVT) n = 17 and pulmonary embolism (PE) n = 20. Complication rates were similar in each group. Based on the Caprini scoring model 92% of patients scored in the “Highest Risk” category. The Caprini RAM accurately predicted all 37 VTEs, all of which scored in the “Highest Risk” category. The percentage of patients that received double prophylaxis increased with time from 12% in 2004 to 63% in 2010. Importantly, 25 of the 37 VTEs (68%) did not receive double prophylaxis.

Conclusions

The use of the Caprini RAM accurately predicted patients at the highest risk of experiencing VTE. Considering accurate identification of patients allows proper administration of double prophylaxis, we recommend the use of this scoring model preoperatively in patients undergoing surgery for gynecologic malignancies.     

剖宫产术后深静脉血栓形成的临床研究

目的:探讨剖宫产术后DVT的诊治及预防。方法:回顾分析2002年8月至2005年12月我科收治的剖宫产术后并发下肢DVT的患者47例,分析其临床特点及诊断治疗的方法,并结合文献复习讨论预防措施。结果:既往有血栓病史、经产妇、肥胖是剖宫产术后DVT的危险因素,主要临床症状为患肢粗肿、疼痛,部分患者有呼吸系统的非特异性症状,DVT的辅助诊断首选血浆D-二聚体检测结合静脉彩色多普勒超声显像。采用全身或局部抗凝、溶栓等药物或手术取栓治疗,部分患者放置可回收性IVCF预防致死性PE,均取得较好的近期疗效。结论:对于存在DVT危险因素的孕产妇,剖宫产手术前后应采取积极预防措施。LMWH是常用的和安全的抗凝药物,能有效预防和治疗DVT。     

Prevention of venous thromboembolism in gynecologic oncology surgery

Gynecologic oncology patients are at a high-risk of postoperative venous thromboembolism and these events are a source of major morbidity and mortality. Given the availability of prophylaxis regimens, a structured comprehensive plan for prophylaxis is necessary to care for this population. There are many prophylaxis strategies and pharmacologic agents available to the practicing gynecologic oncologist. Current venous thromboembolism prophylaxis strategies include mechanical prophylaxis, preoperative pharmacologic prophylaxis, postoperative pharmacologic prophylaxis and extended duration pharmacologic prophylaxis that the patient continues at home after hospital discharge. In this review, we will summarize the available pharmacologic prophylaxis agents and discuss currently used prophylaxis strategies. When available, evidence from the gynecologic oncology patient population will be highlighted.     

围手术期干预对妇科盆腔手术后下肢深静脉血栓的预防作用

目的 探讨采取围手术期干预措施对妇科盆腔手术后下肢深静脉血栓(DVT)的预防作用.方法 将2007年6月至2008年6月于浙江大学医学院附属邵逸夫医院妇产科接受妇科盆腔手术的1062例患者分为干预组和非干预组.对干预组患者进行DVT危险因素评分,根据评分情况分为低、中、高和极高危4种类型,分别采取相应的围手术期干预措施.两组所有患者如术后7 d内出现下肢自发性疼痛、压痛和肿胀,腓肠肌压迫试验或直腿伸踝试验阳性,合并或存在单侧下肢浅表静脉扩张,立即行双下肢静脉彩色多普勒超声检查;干预组中高危和极高危患者于术后第2天和第7天常规行双下肢静脉彩色多普勒超声检查.比较两组患者的DVT发生率,以及手术前后的凝血和纤溶功能等.所有患者在术前1周内、术后48 h时分别检测凝血及纤溶功能.结果 干预组6例发生DVT,发生率为1.10%(6/546);非干预组17例发生DVT,发生率为3.29%(17/516);两组间DVT总发生率比较,差异有统计学意义(P<0.05).干预组中DVT极高危患者的DVT发生率为21.05%(4/19),均分别高于低危(0)、中危(0)、高危者[2.13%(2/94)],差异均有统计学意义(P<0.05).两组患者术后D二聚体及抗凝血酶Ⅲ水平均分别高于术前水平,但差异均无统计学意义(P>0.05).两组患者术后血小板计数、凝血酶原时间、活化部分凝血活酶时间、凝血酶时间及纤维蛋白原、组织型纤溶酶原活化剂、纤溶酶原活化剂抑制剂水平分别比较,差异也均无统计学意义(P>0.05).结论 根据不同的DVT危险分群采取相应围手术期干预能显著降低DVT的发生率,建议加强对高危及极高危人群的DVT预防.     

Deep venous thrombosis in gynecological oncology: Incidence and clinical symptoms study

Objective

Cancer patients have increased risks of leg deep venous thrombosis (DVT). We studied the incidence, risk factors and most predictive symptoms of leg DVT in gynecologic oncology patients.

Study designs

Gynecologic oncology patients with any leg DVT symptoms were recruited and screened using Doppler sonogram. All hospitalized surgery and non-ambulating patients received thigh-high sequential compression devices (SCDs) without heparin as a prophylactic method against thrombosis. Statistical analysis was done using chi-square or Fisher's exact tests.

Results

Out of 1974 patients, 134 complained of lower limb symptoms. Doppler studies found 38 patients with leg DVT. Incidence of leg DVT was 36/853 (4.2%) in patients with cancer and 2/1121 (0.2%) in patients without cancer (odds ratio 2.8 with a diagnosis of cancer). Leg edema, erythema, fever, and warm leg were significant symptoms in diagnosing leg DVT (p < 0.01). The cost of finding a leg DVT was $747.54.

Conclusions

Clinical exam is less accurate than Doppler sonogram in diagnosing leg DVT. The incidence of leg DVT using SCD seems to be comparable with other studies. Finally, the cost of identifying leg DVT seems reasonable.     

Venous thromboembolism prevention in gynecologic cancer surgery: a systematic review

OBJECTIVES: Advanced age, pelvic surgery, and the presence of malignancy place gynecologic oncology patients at high risk for venous thromboembolism (VTE). This study was designed to systematically analyze the world's literature on VTE in these patients and determine the optimal prophylaxis regimen. METHODS: Computerized searches of Pubmed, Ovid, DARE, ACP Journal Club, Cochrane Database of Systematic Reviews, and Cochrane Controlled Trials Registry 1966-2005 were performed, as well as EMBASE 1980-2005. Major conferences and target references were hand-searched. Inclusion criteria were randomized controlled trials (RCTs) evaluating VTE prophylaxis with heparin, low-molecular-weight heparin (LMWH), and sequential compression devices (SCD). The search yielded 278 articles; 11 met inclusion criteria. Data were abstracted by one author and analyzed with the Mantel-Haenszel method. RESULTS: The analysis of heparin-versus-control revealed a significant decrease in DVT in patients receiving heparin (RR=0.58, 95% CI 0.35-0.95). There were no significant differences in EBL or transfusions between the two groups. In the 320 patients in the heparin vs. LMWH studies, there was no significant difference in DVT (RR 0.91, 95% CI 0.38-2.17), although power analysis demonstrated insufficient numbers to show a difference. No patient in either group required re-exploration for bleeding. CONCLUSIONS: All gynecologic cancer patients should receive VTE prophylaxis. Although heparin, LMWH, and SCD have been shown to be safe and effective, due to the paucity of data in the gynecologic oncology literature, no one prevention modality can be considered superior at this time. Adequately powered RCTs are urgently needed to determine the optimal regimen in these high-risk patients.     

妇科手术后下肢深静脉血栓形成21例临床分析

目的探讨妇科手术后下肢深静脉血栓形成（LEDVT）的防治措施。方法收集21例妇科手术后发生LEDVT患者的临床资料，并进行分析。结果妇科恶性肿瘤手术和阴式手术是发生下肢深静脉血栓的高危因素。2例手术取栓，19例经抗凝、溶栓治疗，患者治疗后均好转出院。结论LEDVT是妇科术后的常见并发症，应引起充分重视，对于高危患者并加强预防性治疗；抗凝、溶栓综合治疗是LEDVT的有效治疗手段。     

妇科肿瘤术后并发深静脉血栓的诊治与预防

目的 探讨妇科肿瘤术后并发下肢深静脉血栓（ＤＶＴ）的诊断治疗要点及预防措施。方法回顾性分析１１例妇科ＤＶＴ患者和１８例有ＤＶＴ倾向患者的临床特点及诊断、治疗和预防的方法。结果 发生ＤＶＴ的高危因素为中老年妇女、肥胖、原发病多为贫腔恶性肿瘤,特别是子宫内膜癌。辅助诊断方法以彩色多普勒血流显像为最佳。治疗采用肝素或低分子肝素事速避凝抗凝治疗,均取得较好效果。结论 中老年、肥胖的肿瘤患者,特别是恶性肿瘤     

Venous Thromboembolic Complications to Hysterectomy for Benign Disease: A Nationwide Cohort Study

Study Objective

To estimate the risk of venous thromboembolic complications after abdominal, laparoscopic, and vaginal hysterectomy when performed for benign disorders.

Ovarian vein thrombosis after bilateral adnexectomy in a symptomatic patient with concomitant pulmonary embolism: A case report

ObjectiveOvarian vein thrombosis (OVT) after adnexectomy is usually asymptomatic, and pulmonary embolism (PE) has not been reported following this type of OVT. We present the case of a patient with symptomatic OVT after bilateral adnexectomy who experienced PE.Case reportA 52-year-old woman underwent total laparoscopic hysterectomy and bilateral adnexectomy for early stage endometrial cancer. On the 12th postoperative day, she presented with a fever of 38.7 °C. Computed tomography (CT) revealed bilateral OVT. Anticoagulant and antibacterial therapy was initiated; after five days, the fever subsided. On the 19th postoperative day, CT revealed a decrement in OVT; however, PE was observed. By the 60th postoperative day, PE disappeared. No deep vein thromboses were detected at any time.ConclusionThis case highlights that OVT, even after adnexectomy, can cause symptoms and PE can occur after this type of OVT. Anticoagulation therapy may be considered in such cases.     

Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of low molecular weight heparin. Gynecological ward retrospective analysis

Objectives: To compare the frequency of deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing gynecological operations without low molecular weight heparin (LMWH) prophylaxis and those receiving such prophylaxis. Design: Retrospective, hospital record-based study. Material and Methods: About 1785 consecutive patients without LMWH prophylaxis and 1871 ones treated with nadroparin (Fraxiparine) 7500 ICU s.c. 2 h before the operation and repeated daily for 5–7 days or until the patient was fully mobile. DVT was diagnosed on the basis of clinical symptoms and ultrasound examination, and PE on clinical symptoms, gasometric data, electrocardiography and chest X-ray. Results: Among the patients without prophylaxis, four cases of PE occurred (0.22%), two fatal (0.11%), 13 cases of proximal DVT (0.72%) and 41 distal DVT complications (2.3%). In LMWH, group 3 proximal DVT (0.16%) and 18 distal DVT (0.96%) developed but there were no clinically expressed pulmonary embolism. According to the Fisher’s exact test, the difference between the complications in the analyzed groups is significant P<0.05. Conclusion: The perioperative applying of LMWH to prevent DVT in the patients operated on gynecologically is effective.     

Evaluation of Doppler test for venous thrombosis in obstetrics and gynecology

The use of the ultrasonic Doppler test to diagnose venous thrombosis was evaluated in an obstetric and gynecological unit. Both asymptomatic postoperative patients and those with suspected venous thrombosis were studied.Detection of ilio-femoral thrombosis was possible, but the incidence in unselected gynecological patients was low. The technique was of greater value in clarifying the diagnosis in suspected venous thrombosis.     

间歇性气囊加压与低分子肝素预防妇科良性病变手术治疗后下肢深静脉血栓形成的对比研究

目的:比较间歇性气囊加压和低分子肝素对预防妇科良性病变手术治疗后下肢深静脉血栓的预防效果。方法:将157例患者随机分为间歇性气囊加压(IPC)预防组(79例)与低分子肝素(LMWH)预防组(78例),术后1周内采用加压超声检查诊断深静脉血栓(DVT),比较患者手术前后的血常规、凝血检查等数据,并记录术中、术后并发症。结果:共发生4例DVT(2.5%),1例PE(0.6%)。IPC组2例DVT;LMWH组2例DVT,其中1例合并PE。4例DVT患者年龄均在60岁以上。两组患者的术后血红蛋白(Hb)、血小板(PLT),凝血酶时间(TT)均较术前显著减少(均为P0.001),D二聚体(Ddimer)、凝血酶原时间(PT)、活化部分凝血酶时间(APTT)和纤维蛋白原(Fbg)均显著增加(P0.01)。IPC组和LMWH组的抗凝血酶III(Anti-thrombin III,AT-III)手术前后变化无显著差异(P=0.686,P=0.061)。IPC与LMWH两组间手术前后Hb、PLT、D-dimer、PT、APTT、Fbg、TT、AT-III无显著差异。IPC组发生术后出血1例(1.7%),LMWH组发生术后出血7例(9.0%)。结论:对于因良性疾病行妇科手术的患者,应采取措施预防DVT,尤其是60岁以上的患者。IPC或LMWH均可有效减少术后DVT发生率,且IPC可取得与LMWH一致的血栓预防效果,并有较低的术后出血率。     

妊娠期肺栓塞的预防与处理

孕妇是肺栓塞的高发人群,遗传性或获得性易栓症等因素的存在更增加了发病风险。妊娠期的生理性改变和胎儿因素,使妊娠期肺栓塞的诊断变得复杂和困难。治疗首选低分子量肝素,溶栓治疗须严格掌握适应证和禁忌证。     

妇科肿瘤术后深静脉血栓和肺栓塞的防治

妇科肿瘤术后血液淤滞、高凝状态是深静脉血栓(DVT)和肺栓塞(PE)形成的主要原因.影像学检查在DVT和PE的诊断上占有重要地位.抗凝治疗是DVT和PE的主要治疗方法.     

Significance of venous thromboembolism in women with uterine carcinosarcoma

Objective

To identify risk factors for venous thromboembolism (VTE) and to examine the association of VTE and survival in women with uterine carcinosarcoma.

影像学检查在妊娠期静脉血栓栓塞症诊断中的应用

静脉血栓栓塞症在妊娠期发生率较正常人明显增高,是妊娠期的一种严重并发症。下肢深静脉血栓形成与肺栓塞有重要相关性,及早发现,及时治疗可改善孕产妇预后。影像学检查在静脉血栓栓塞症的诊断方面具有重要作用。     

高危子宫内膜癌卡铂和紫杉醇联合化疗后静脉血栓发生情况分析#br#

Objective?To analyze the incidence and influencing factors of venous thrombosis after carboplatin and paclitaxel combined chemotherapy in high-risk endometrial carcinoma. Methods?A total of 98 patients with high-risk endometrial cancer who were treated in our hospital were selected and treated with carboplatin+paclitaxel (TC) chemotherapy. According to the occurrence of venous thrombosis after chemotherapy, they were divided into the occurrence group and the non-occurrence group, and the influence of chemotherapy was analyzed. Logistic multivariate regression analysis was used to summarize the related factors affecting the occurrence of venous thrombosis. Results?The incidence of venous thrombosis in patients was 17.35%. The most common site of thrombosis was the subclavian vein (7 cases, 41.18%). FIGO stageⅢ, D-dimer≥0.5 mg/L before chemotherapy, traditional puncture, and cubital puncture were independent risk factors for venous thrombosis after TC chemotherapy for high-risk endometrial cancer, and puncture of the precious vein was a protective factor (P<0.05). Conclusion?Patients with high-risk endometrial cancer have a higher risk of venous thrombosis in upper extremity veins after chemotherapy with TC regimen, and the influencing factors include clinical stage, coagulation function status, puncture method, puncture site, and blood vessel selection.     

Recommendations for the diagnosis and treatment of deep venous thrombosis and pulmonary embolism in pregnancy and the postpartum period

Venous thromboembolism (VTE) in pregnancy and the postpartum is an important cause of maternal morbidity and mortality; yet, there are few robust data from clinical trials to inform an approach to diagnosis and management. Failure to investigate symptoms suggestive of pulmonary embolism (PE) is a consistent finding in maternal death enquiries, and clinical symptoms should not be relied on to exclude or diagnose VTE. In this consensus statement, we present our recommendations for the diagnosis and management of acute deep venous thrombosis (DVT) and PE. All women with suspected DVT in pregnancy should be investigated with whole leg compression ultrasonography. If the scan is negative and significant clinical suspicion remains, then further imaging for iliofemoral DVT maybe required. Imaging should be undertaken in all women with suspected PE, as the fetal radiation exposure with both ventilation/perfusion scans and CT pulmonary angiography is within safe limits. Low-molecular-weight heparin (LMWH) is the preferred therapy for acute VTE that occur during pregnancy. In observational cohort studies, using once-daily regimens appears adequate, in particular with the LMWH tinzaparin; however, pharmacokinetic data support twice-daily therapy with other LMWH and is recommended, at least initially, for PE or iliofemoral DVT in pregnancy. Treatment should continue for a minimum duration of six months, and until at least six weeks postpartum. Induction of labour or planned caesarean section maybe required to allow an appropriate transition to unfractionated heparin to avoid delivery in women in therapeutic doses of anticoagulation.