Timing of heparin prophylaxis and bleeding complications in hysterectomy a nationwide prospective cohort study of 9,949 Danish women.

OBJECTIVE

To examine bleeding complications and thromboembolic events in relation to timing of heparin prophylaxis after hysterectomy.

DESIGN

Nationwide prospective cohort study with 30 days post-operative follow-up within the Danish Hysterectomy Database (DHD).

SETTING

All gynecological departments in Denmark (n=31).

SAMPLE

9,949 women who had an elective hysterectomy for benign indication between October 2003 and May 2006 and were reported to DHD (national response rate: 88-99% throughout 2004-2005).

MAIN OUTCOME MEASURES

Odds ratios (OR) of peri-operative bleeding complications (> or =1,000 ml bleeding during surgery or post-operative wound/vaginal-vault/intraabdominal bleeding or hematoma) and number of events of venous thromboembolism. Logistic regression analysis adjusting for: age, body mass index, alcohol, smoking, meno-/metrorrhagia, uterine weight, department volume, surgeon's experience, route and type of hysterectomy and additional surgery, and stratification on assistant's experience, peri-operative pain prophylaxis with NSAID and daily use of Acetyl Salicylic Acid (ASA)/NSAID.

RESULTS

9,051 women (92%) received thromboprophylaxis with heparin, initiated pre-operatively in 48% and post-operatively in 52%. At least one bleeding complication was noted in 881 women (10%). Post-operative heparin administration was associated with a reduced risk of bleeding complications; OR=0.85 (95% confidence interval 0.73-0.99) compared to pre-operative administration. Excluding cases with potential impaired hemostasis at baseline, the OR was 0.78 (0.64-0.94). There was no fatal embolism. Three of seven pulmonary embolisms and one of three symptomatic deep venous thromboses occurred with the post-operative heparin administration.

CONCLUSION

Post-operative rather than pre-operative administration of heparin prophylaxis may reduce the risk of bleeding complications after hysterectomy without apparent risk of increased thromboembolic events.