Blood management in patients with uterine myoma and anemia in the perioperative period

   Introduction. In the structure of gynecological diseases, uterine myoma occupies one of the leading places and is accompanied by abnormal uterine bleeding, anemia, hemodynamic and hemostasiological disorders.
   Purpose. To optimize the management of the perioperative period in patients with uterine myoma and iron deficiency anemia (IDA) using methods of patient blood management (PBM).
   Materials and methods. The study group consisted of 94 patients with uterine myoma and IDA, who were examined and treated at the Kulakov National Medical Research Center of Obstetrics, Gynecology and Perinatology. Of these, 74 patients made up the first, prospective group, who received IDA treatment with intravenous administration of ferric carboxymaltose during the perioperative period and during surgical treatment (laparoscopy / laparotomy and myomectomy), they underwent intraoperative autologous blood transfusion (IABT) using the cell salvage with Cell Saver 5+ apparatus. 20 women with myoma uterine and IDA constituted a comparison group (retrospective) who did not receive intravenous iron therapy in the perioperative period and did not undergo IABT. During surgical intervention (laparoscopy / laparotomy and myomectomy) or in the postoperative period, they received transfusion of donor erythrocyte-containing blood components according to indications.
   Results. All patients underwent surgical treatment in the amount of laparoscopy / laparotomy and myomectomy. During the operation, 74 patients of the main group underwent IABT in an average volume of 467.4 ± 327.8 ml. In the postoperative period, the patients of the main group continued to receive anemia therapy with intravenous administration of ferric carboxymaltose. And blood transfusions were not required in any patient of the main group. In patients of the second group, two (10 %) patients received donor erythrocyte suspension in an average volume of 358.2 ± 85.8 ml. Infectious and inflammatory complications: fever, inflammation of the postoperative suture, parametritis occurred in 6.8 % of women in the main group; in the comparison group – in 15 % of patients.
   Conclusions. Introduction into clinical practice of modern methods of blood management in patients with uterine myoma and IDA: the Infusion of intravenous high-dose ferric preparationsin the perioperative period, the use of Cell Saver devices for intra-operative autologous blood transfusion, helps to reduce the time of therapy, minimize transfusions of donor erythrocytes, reducing the frequency of infectious and inflammatory complications.

1. Адамян Л. В. Миома матки: клинические рекомендации / Л. В. Адамян [и др.] – М., 2020. – 32 с. Режим доступа: https://cr.minzdrav.gov.ru/schema/257_1. – Adamyan L. V., Andreeva E. N., Absatarova Yu. S., Artymuk N. V., Belokrinitskaya T. E., Bezhenar V. F. et al. Uterine fibroids: clinical guidelines. Moscow; 2020. 32 p. (In Russ.) Available at: https://cr.minzdrav.gov.ru/schema/257_1.

2. Тайц А. Н. Современные представления о патогенезе миомы матки / А. Н. Тайц [и др.] // Педиатр. – 2019. – 10 (1): 91–99. https://doi.org/10.17816/PED10191-99. – Taits A. N., Rukhlyada N. N., Matukhin V. I., Somova A. D., Dudova K. A. Contemporary concepts of uterine fibroids’ pathogenesis. Pediatrician (St. Peter sburg). 2019; 10 (1): 91–99. (In Russ.) https://doi.org/10.17816/PED10191-99.

3. Серов В. Н. Диагностика и лечение периоперационной анемии и дефицита железа у хирургических пациентов / В. Н. Серов [и др.] – Чебоксары: Среда 2021. – 60 с. Режим доступа: https://phsreda.com/e-publications/e-publication-10284.pdf. – Serov V. N., Fedorova T. A., Pyregov A. V., Rogachevskiy O. V., Shmakov R. G. et al. Diagnosis and treatment of perioperative anemia and iron deficiency in surgical patients. Cheboksary: Sreda; 2021. 60 p. (In Russ.) Available at: https://phsreda.com/e-publications/e-publication-10284.pdf.

4. Isbister J. P. The three- pillar matrix of patient blood management – an overview. Best Pract Res Clin Anaesthesiol. 2013; 27 (1): 69–84. https://doi.org/10.1016/j.bpa.2013.02.002.

5. Gombotz H. Patient Blood Management: A Patient-Orientated Approach to Blood Replacement with the Goal of Reducing Anemia, Blood Loss and the Need for Blood Transfusion in Elective Surgery. Transfus Med Hemother. 2012; 39 (2): 67–72. https://doi.org/10.1159/000337183.

6. Кудрина Е. А. Миома матки: современные аспекты патогенеза и лечения (клиническая лекция) / Е. А. Кудрина, Д. В. Бабурин // Архив акушерства и гинекологии им. В. Ф. Снегирева. – 2016. – 3 (1): 4–10. https://doi.org/10.18821/2313-8726-2016-3-1-4-10. – Kudrina E. A., Baburin D. V. Uterine myoma: modem aspects of pathogenesis and treatment (clinical lecture). V. F. Snegirev Archives of Obstetrics and Gynecology. 2016; 3 (1): 4–10. (In Russ.) https://doi.org/10.18821/2313-8726-2016-3-1-4-10.

7. El- Balat A., DeWilde R. L., Schmeil I., Tahmasbi-Rad M., Bogdanyova S., Fathi A., Becker S. Modern Myoma Treatment in the Last 20 Years: A Review of the Literature. Biomed Res Int. 2018: 4593875. https://doi.org/10.1155/2018/4593875.

8. Zdanowicz J. A., Surbek D. Patient blood management in obstetrics – Review. Transfus Apher Sci. 2019; 58 (4): 412–415. https://doi.org/10.1016/j.transci.2019.06.017.

9. Althoff F. C., Neb H., Herrmann E., Trentino K. M., Vernich L., Füllenbach C. et al. Multimodal Patient Blood Management Program Based on a Threepillar Strategy: A Systematic Review and Meta-analysis. Ann Surg. 2019; 269 (5): 794–804. https://doi.org/10.1097/SLA.0000000000003095.

10. Muñoz M., Acheson A. G., Auerbach M., Besser M., Habler O., Kehlet H. et al. International consensus statement on the peri-operative management of anaemia and iron deficiency. Anaesthesia. 2017; 72 (2): 233–247. https://doi.org/10.1111/anae.13773.

11. Nash Z. J., Kunde K., Mascarenhas L. J. The role of intraoperative cell salvage in abdominal myomectomy. Am J Obstet Gynecol. 2014; 211 (4): 440–441. https://doi.org/10.1016/j.ajog.2014.05.019.

12. Froessler B., Palm P., Weber I., Hodyl N. A., Singh R., Murphy E. M. The Important Role for Intravenous Iron in Perioperative Patient Blood Management in Major Abdominal Surgery: A Randomized Controlled Trial. Ann Surg. 2016; 264 (1): 41–46. https://doi.org/10.1097/SLA.0000000000001646.

13. Elhenawy A. M., Meyer S. R., Bagshaw S. M., MacArthur R. G., Carroll L. J. Role of preoperative intravenous iron therapy to correct anemia before major surgery: a systematic review and meta-analysis. Syst Rev. 2021; 10 (1): 36. https://doi.org/10.1186/s13643-021-01579-8.

14. Litton E., Xiao J., Ho K.M. Safety and efficacy of intravenous iron therapy in reducing requirement for allogeneic blood transfusion: systematic review and meta-analysis of randomised clinical trials. BMJ. 2013; 347: f4822. https://doi.org/10.1136/bmj.f4822.

15. Froessler B., Rueger A. M., Connolly M. P. Assessing the costs and benefits of perioperative iron deficiency anemia management with ferric carboxymaltose in Germany. Risk Manag Healthc Policy. 2018; 11: 77–82. https://doi.org/10.2147/RMHP.S157379.

16. Favrat B., Balck K., Breymann C., Hedenus M., Keller T., Mezzacasa A., Gasche C. Evaluation of a single dose of ferric carboxymaltose in fatigued, iron-deficient women – PREFER a randomized, placebo- controlled study. PLoS ONE. 2014; 9 (4): e94217. https://doi.org/10.1371/journal.pone.0094217.

17. Khalafallah A. A., Yan C., Al-Badri R., Robinson E., Kirkby B. E., Ingram E. et al. Intravenous ferric carboxymaltose versus standard care in the management of postoperative anaemia: a prospective, open-label, randomised controlled trial. Lancet Haematol. 2016; 3 (9): e415–425. https://doi.org/10.1016/S2352-3026(16)30078-3.

18. Сухих Г. Т. Кровесберегающие технологии у гинекологических больных: клинические рекомендации / Г. Т. Сухих [и др.] – М., 2015. – 29 с. Режим доступа: https://old.minzdravao.ru/sites/default/files/2015/krovosberegayushchie_tehnologii_u_ginekologicheskih_bolnyh.pdf. – Sukhikh G. T., Adamyan L. V., Serov V. N., Baev O. V., Bashmakova N. V., Bakuridze E. M. et al. Blood­saving technologies in gynecological patients: clinical recommendations. Moscow; 2015. 29 p. (In Russ.) Available at: https://old.minzdravao.ru/sites/default/files/2015/krovosberegayushchie_tehnologii_u_ginekologicheskih_bolnyh.pdf.

19. Kuppurao L., Wee M. Perioperative cell salvage. Continuing Education in Anaesthesia, Critical Care and Pain. 2010; 10 (4): 104–108. https://doi.org/10.1093/bjaceaccp/mkq017.

20. Liu Y., Li X., Che X., Zhao G., Xu M. Intraoperative cell salvage for obstetrics: a prospective randomized controlled clinical trial. BMC Pregnancy Childbirth. 2020; 20 (1): 452. https://doi.org/10.1186/s12884-020-03138-w.

21. Курилович Е. О. Социально-экономические выгоды адекватной коррекции дефицита железа у беременных / Е. О. Курилович [и др.] // Акушерство и гинекология. – 2021. – (9): 212–220. https://doi.org/10.18565/aig.2021.9.212-220. – Kurilovich E. O., Volkova O. I., Fedorova T. A., Golubtsov V. V., Popovich L. D., Andreeva M. D. et al. Socioeconomic benefits from adequate correction of iron deficiency in pregnant women. Akusherstvo i Ginekologiya (Russian Federation). 2021; (9): 212–220. (In Russ.) https://doi.org/10.18565/aig.2021.9.212-220.

22. Leahy M. F., Hofmann A., Towler S., Trentino K. M., Burrows S. A., Swain S. G. et al. Improved outcomes and reduced costs associated with a health-system-wide patient blood management program: a retrospective observational study in four major adult tertiary-care hospitals. Transfusion. 2017; 57 (6): 1347–1358. https://doi.org/10.1111/trf.14006.

23. Meybohm P., Froessler B., Goodnough L. T., Klein A. A., Muñoz M., Murphy M. F. et al. Simplified International Recommendations for the Implementation of Patient Blood Management (SIR4PBM). Perioper Med (Lond). 2017; 6: 5. https://doi.org/10.1186/s13741-017-0061-8.