الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Venous thromboembolism represents a major problem after gynecologic operations. Pharmacologic prophylaxis with enoxaparin decreases the risk of postoperative VTE.
The aim of the present study was to study the pattern of use of prophylactic enoxaparin after gynecologic operations in EL-Shatby Maternity University Hospital.The specific objectives were to describe the pattern of use of prophylactic enoxaparin in gynecologic operations, to review to what extent the gynecologists are following the recommended guidelines of the ACCP for VTE prophylaxis, and to assess the knowledge of gynecologists regarding VTE and the use of enoxaparin in gynecologic operations.
A retrospective case series was conducted where all available data for the years 2012-2017 were reviewed to collect data about socio-demographic characteristics of patients (age, marital status, educational level and residence), medical history of patients including certain diseases (diabetes mellitus, hypertension, history of VTE), obstetric history of the patient (parity, gravidity, and abortion), gynecologic history ( gynecological diseases and surgery), pre and postoperative intake of enoxaparin (dose, frequency, duration and purpose of use), and laboratory investigations (complete blood count, and clotting factors).
A cross sectional study was also conducted usinga predesigned self-administered structured questionnaire to collect the following data from the resident gynecologists:socio-demographic data of the gynecologists (age, sex, rank and post graduate studies), knowledge about VTE (clinical picture, risk factors and its relation with some diseases like cancer), enoxaparin (indications, recommended dose, frequency, duration, side effects and contraindications) and availability of ACCP guidelines and adherence and reasons for lack of compliance with these guidelines.
Data entry and statistical analysis were done using the software Statistical Package for Social Science (SPSS) version 23. Statistical analysis was performed in both descriptive and inferential forms.
The study revealed the following main results:
Results of the cross sectional study:
• The age of the gynecologists ranged between 25 and 30 years with a mean of 26.64 ± 1.37.
• Half of the studied gynecologists were males and the other half were females.
• Regarding the rank, junior staff constituted46.4%.An equal percent (25%) were mid senior and senior staff and registrars constituted 3.6%.
• The majority of gynecologists (82.1%) had post graduate studies.
• The years of experience ranged between 1 and 5 years with a mean of 1.89 ± 1.09 years.
• The majority of gynecologists (75%) believed that VTE causes sudden death in postoperative patients.
• Most gynecologists (96.4%) thought there is a relation between VTE and other diseases.
• The majority of gynecologists (85.7%) stated that enoxaparin is used for VTE prophylaxis.
• About 71.4 % of gynecologists stated that bleeding is the major side effect of enoxaparin.
• Regarding the VTE knowledge score, it appears from the table that the mean VTE score was57.2981±21.40005 where more than one third (35.7%) of residents had poor score, 42.9% of fair score and 21.4% good score.
• Regarding the enoxaparin knowledge score, the mean enoxaparin score was 59.9206 ±18.84631 where about 17.9% of residents had poor knowledge score, 60.7% had fair knowledge score and only 21.4% had good knowledge score.
• The overall knowledge score was 30.91%-92.73% with a mean of 68.05±13.31
• The majority of gynecologists (96.4%) mentioned that guidelines were not available in the hospital.
• One-way MANOVA indicated a significant impact of rank (F = 3.748, p = .048. on awareness about Venous thromboembolism prophylaxis in gynecologic operations.
Section II: Results of record review
• About two thirds (67.6%) of the patients were above 40 years and 32.4% were below 40 years with a mean of 45.77 ± 11.37 years.
• More than three quarters of patients (77.3%) were married, 11% were widowed, 8.1% were single and 3.7% were divorced.
• More than half of the patients (54.6%) had medical history of diseases like hypertension, DM, hepatic diseases, cardiac diseases and cancer and 38.8% of the patients had surgical history.
• Half of patients (57.2%) had uterine fibroids.
• The majority (99.4%) of patients had no history of VTE whereas only 0.6% of patients had.
• Regarding obstetric and gynecologic data, 42.2% of patients had more than four pregnancies with a mean of 3.62 ± 2.67, 65.9% of the patients underwent dilation and curettage, 18.9% underwent laparoscopic cystectomy, about 11.4% underwent myomectomy and only 5.3% of the patients underwent hysterectomy.
• Among those who received enoxaparin (282 out of 621 patient), 49.6% of them received it preoperatively, while 50.4% received it postoperatively. 68.6% of patients received a dose of 40 mg, 26.4% a dose of 60 mg, 3.6% a dose of 20 mg and 1.4% received 80 mg. Those who received preoperative enoxaparin once daily constituted 92.9%, and 7.1% of patients received preoperative enoxaparin twice daily. Patients who received preoperative enoxaparin for one day constituted 91.4%. Those who received preoperative enoxaparin for two days were 5.7%. Patients who received preoperative enoxaparin for three days constituted 5.7%. Those who received preoperative enoxaparin for more than three days were 1.4%. Regarding the purpose of use of enoxaparin, it was for thromboprophylaxis in 98.6% of patients and 1.4% as treatment of current thrombus. Regarding the pattern of use of postoperative enoxaparin, 69.7% of patients received 40 mg, 26.8% received 60 mg, 2.8% received 80 mg and 0.7% of them received 20 mg. Patients who took postoperative enoxaparin once daily constituted 95.1%. Those who received postoperative enoxaparin twice daily constituted 4.9%. Patients who took postoperative enoxaparin for one day constituted 64.1%. Those who received postoperative enoxaparin for two days were 28.2%. 6.3% of patients received postoperative enoxaparin for three days. 1.4% of patients received postoperative enoxaparin for more than three days. Regarding the purpose of use of enoxaparin, it was for thromboprophylaxis in 99.3% of patients and for treatment of current thrombus in 0.7%.
• Logistic regression analysis showed that diagnosis was a significant predictor for enoxaparin score. The ROC curve of probability of good score calculated from binary logistic regression model among patients shows that the area under the curve (AUC) was 0.691 (CI 0 .590, .791 and p = .002)
Based on the results of the current study, the following can be concluded:
• Gynecologic operations puts women at increased risk of VTE and 72.6% of the patients should have received prophylaxis whereas only one quarter of them received prophylaxis.
• The use of enoxaparin as a VTE prophylactic drug is not following the international guidelines.
• The risk of VTE is not assessed for each individual patient.
• Enoxaparin prophylaxis for four weeks after gynecologic operations for cancer is necessary in reducing the incidence of VTE.
• The overall knowledge score was 30.91%-92.73% with a mean of 68.05±13.31 and only17.9% were of good score of knowledge.
• One-way MANOVA indicated a significant impact of rank (F = 3.748, p = .048. on awareness about VTE prophylaxis in gynecologic operations.
• Logistic regression analysis showed that diagnosis was a significant predictor for enoxaparin score.
The main recommendations of the study are:
A. Recommendations to the Ministry of Health and population:
• The Ministry of Health and Population should provide the University hospitals and the ministry of Health and Population hospitals with guidelines on VTE prophylaxis.
• There is a need for continuous educationof health care providers on VTE and its importance through organizations of workshops and training programs.
• Guidelines for antithrombotic regimens should be available in hospitals to help physicians apply them easily.
• A surveillance system should be established to measure VTE events following gynecologic operations.
B. Recommendations to physicians:
Physicians should be educated about the importance of adherence to guidelines for VTE prophylaxis to prevent its occurrence.
C. Recommendations to researchers:
• Further researches are required to detect the effect of applying the recommended guidelines on the prevention of VTE.
• There should be risk assessment tools to identify the high risk patients for VTE.