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Risk of thrombosis and bleeding in gynecologic noncancer surgery: systematic review and meta-analysis

Lookup NU author(s): Sanjay PandanaboyanaORCiD



This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0).


Objective: This study aimed to provide procedure-specific estimates of the risk for symptomatic venous thromboembolism and major bleeding in noncancer gynecologic surgeries.Data sources: We conducted comprehensive searches on Embase, MEDLINE, Web of Science, and Google Scholar. Furthermore, we performed separate searches for randomized trials that addressed the effects of thromboprophylaxis.Study eligibility criteria: Eligible studies were observational studies that enrolled ≥50 adult patients who underwent noncancer gynecologic surgery procedures and that reported the absolute incidence of at least 1 of the following: symptomatic pulmonary embolism, symptomatic deep vein thrombosis, symptomatic venous thromboembolism, bleeding that required reintervention (including re-exploration and angioembolization), bleeding that led to transfusion, or postoperative hemoglobin level <70 g/L.Methods: A teams of 2 reviewers independently assessed eligibility, performed data extraction, and evaluated the risk of bias of the eligible articles. We adjusted the reported estimates for thromboprophylaxis and length of follow-up and used the median value from studies to determine the cumulative incidence at 4 weeks postsurgery stratified by patient venous thromboembolism risk factors and used the Grading of Recommendations Assessment, Development and Evaluation approach to rate the evidence certainty.Results: We included 131 studies (1,741,519 patients) that reported venous thromboembolism risk estimates for 50 gynecologic noncancer procedures and bleeding requiring reintervention estimates for 35 procedures. The evidence certainty was generally moderate or low for venous thromboembolism and low or very low for bleeding requiring reintervention. The risk for symptomatic venous thromboembolism varied from a median of <0.1% for several procedures (eg, transvaginal oocyte retrieval) to 1.5% for others (eg, minimally invasive sacrocolpopexy with hysterectomy, 1.2%-4.6% across patient venous thromboembolism risk groups). Venous thromboembolism risk was <0.5% for 30 (60%) of the procedures; 0.5% to 1.0% for 10 (20%) procedures; and >1.0% for 10 (20%) procedures. The risk for bleeding the require reintervention varied from <0.1% (transvaginal oocyte retrieval) to 4.0% (open myomectomy). The bleeding requiring reintervention risk was <0.5% in 17 (49%) procedures, 0.5% to 1.0% for 12 (34%) procedures, and >1.0% in 6 (17%) procedures.Conclusion: The risk for venous thromboembolism in gynecologic noncancer surgery varied between procedures and patients. Venous thromboembolism risks exceeded the bleeding risks only among selected patients and procedures. Although most of the evidence is of low certainty, the results nevertheless provide a compelling rationale for restricting pharmacologic thromboprophylaxis to a minority of patients who undergo gynecologic noncancer procedures.

Publication metadata

Author(s): Lavikainen L, Guyatt G, Kalliala IEJ, et al, ROTBIGGS Investigators, Pandanaboyana S

Publication type: Article

Publication status: Published

Journal: American Journal of Obstetrics and Gynecology

Year: 2024

Volume: 230

Issue: 4

Pages: 390-402

Print publication date: 01/04/2024

Online publication date: 10/12/2023

Acceptance date: 28/11/2023

Date deposited: 19/04/2024

ISSN (print): 0002-9378

ISSN (electronic): 1097-6868

Publisher: Mosby, Inc.


DOI: 10.1016/j.ajog.2023.11.1255

PubMed id: 38072372


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Funder referenceFunder name
Academy of Finland
Finnish Medical Foundation
Helsinki University Hospital
Sigrid Jusélius Foundation
Tampere University Hospital
Turku University Hospital