Role of Blood Management in Optimizing Perioperative Outcomes in Patients With Secondary Anemia Undergoing Hysterectomy or Myomectomy for Abnormal Uterine Bleeding: A Proposed Randomized Control Trial

Title : Role of blood management in optimizing perioperative outcomes in patients with secondary anemia undergoing hysterectomy or myomectomy for abnormal uterine bleeding: A Proposed Randomized Control Trial

I. Background/Introduction:

According to the World Health Organization (WHO), 30.2 % of the world's population of nonpregnant women are anemic, with a higher percentage of anemia being encountered in patients seeking surgical management of abnormal uterine bleeding (AUB). Age, gender, socioeconomic factors, nutrition, and certain pathologic states are associated with iron depletion and associated iron deficiency anemia. Uterine fibroid (or leiomyoma) is the most common diagnosis associated with hysterectomy, accounting for approximately 31% of all procedures performed. Abnormal uterine bleeding and endometriosis are the second and third most common diagnoses associated with hysterectomy, explaining 14% and 11%, respectively. Based on the diagnoses recorded in the medical record by providers, 48.7% of patients were presumed to have dysfunctional uterine bleeding (DUB) and 9% were presumed to have bleeding secondary to uterine fibroids. In this population of women with AUB, 350 (92.3%) had a hemoglobin concentration recorded. Thirty-five percent were anemic with a hemoglobin of <12g/dL and 13.7% had moderate to severe anemia with a hemoglobin of <10 g/dL.

In addition to the high incidence of secondary anemia in patients with abnormal uterine bleeding and fibroids, surgeries for abnormal uterine bleeding and fibroids such as hysterectomy and myomectomy can involve a significant blood loss. The overall rate of postoperative blood transfusion for hysterectomy in the cited study was 13.3%. The need for packed red blood cell transfusion is one of the known complications of surgery and is increased in women who are noted to be anemic preoperatively. Blood transfusions are associated with increased adverse surgical outcomes. Higher rates of morbidity and mortality have been reported in patients receiving one unit of packed red blood cells compared with patients who did not undergo transfusion. The WHO recommends, in compliance with their guide for optimal clinical use, "that before surgery every reasonable measure should be taken to optimize the patient's own blood volume" . Pre-operative hemoglobin less than 10.6 g/dL versus greater than or equal to 13.1 g/dL had five times the odds of transfusion.

Anemia is a modifiable risk factor that can be assessed and optimized pre-operatively. Prior studies have evaluated preoperative blood management strategies in oncology patients, patients undergoing general surgery procedures, and orthopedic surgery. A systematic review of the management of perioperative anemia showed varying results in change in hemoglobin levels after blood management intervention, but all studies were able to show a decrease in postoperative blood transfusions. A randomized control trial evaluating oral iron supplementation preoperatively in patients undergoing colorectal surgery reported reduced blood transfusion rates in the group receiving this intervention. Froessler et al studied perioperative IV iron intervention in patients undergoing major abdominal surgery in a randomized control trial with using blood transfusions as a primary endpoint. They concluded that perioperative IV iron reduced the need for blood transfusion and was also associated with higher postoperative hemoglobin and shorter hospital stay. A blood management protocol implemented in the perioperative period also noted a decrease in perioperative blood transfusion and postoperative anemia in the orthopedic population. The interventions used in their blood protocol management included erythropoietin, ferric carboxymaltose, and tranexamic acid.