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Estimated Blood Loss During Dilation and Extraction by Anesthetic Type
Abstract Number: T-17
Abstract Type: Original Research
Introduction: Dilation and evacuation (D&E) account for 10-15% of the 42 million abortions that are performed worldwide1. These procedures are commonly performed in the 2nd trimester with either a general anesthetic, a neuraxial technique, or monitored anesthetic care (MAC)2. Bleeding is a serious complication of these procedures3, resulting in greater risk of transfusion, morbidity and mortality4. Volatile anesthetics are known to cause uterine relaxation and may increase this risk. This retrospective study investigates differences in estimated blood loss (EBL) between D&Es performed under GA vs MAC.
Materials and Methods: A chart review from 2008 to 2014 was performed utilizing the D&E CPT code to identify cases for the study. Anesthetic and operative reports (n = 298) for D&E’s performed at UWMC in the OR were reviewed. Cases were analyzed by anesthesia type and EBL as reported by the anesthesia team and OB provider. Cases without a numerical EBL or performed under neuraxial anesthesia or TIVA were excluded from the statistical analysis. The primary outcome was EBL at the time of procedure, while secondary outcomes included aspiration, gynecological complications, EBL greater than 500cc, need for transfusion, and use of uterotonic medications.
Results: 298 cases were included in the analysis; gestational age range was 14 weeks to 25 weeks. 121 procedures were performed under GA and 178 under MAC. Mean EBL for D&Es performed under GA was 332 mL, versus 123 mL for the procedures performed under MAC (p<0.001). Carboprost, methylergonovine, and misoprostol were more commonly used for D&Es performed under GA versus MAC (17.5% vs 6.7%, p<0.001). Complications, as defined above, were higher for GA versus MAC (22.5% vs 3.4%, p < 0.001). Differences remained statistically significant when controlling for gestational age and indication for D&E.
Conclusions: There was a highly significant difference in mean EBL for D&E procedures performed under MAC compared to those under GA with volatile anesthetics. It should be noted that the choice of a GA over MAC in the anesthetic care of these patients may be due to already perceived increased risk of hemorrhage. Also of note, there were no aspiration events recorded in the anesthetic record of any of the MAC group. Randomized control trials are needed to elucidate the effects of anesthetic agents on blood loss during D&Es.
1. ACOG Practice bulletin No 135. 2nd trimester abortion.
2. Dalton VK, et al. Patient preferences, satisfaction, and resource use in office evacuation of early pregnancy failure. Obstet Gynecol. 2006 Jul;108(1):103-10.
3. Pauli E, et al Morbidity of dilatation and evacuation in the second trimester: An analysis. Gynakol Geburtshilfliche Rundsch. 2005 Apr;45(2):107-15.
4. Gutierrez MC,, et al Postpartum hemorrhage treated with a massive transfusion protocol at a tertiary obstetric center: A retrospective study. International Journal of Obstetric Anesthesia. 2012 7;21(3):230-5.