Perioperative nonhormonal pharmacological interventions for bleeding reduction during open and minimally invasive myomectomy: a systematic review and network meta-analysis

Abstract

Objective: To synthesize evidence on the most effective pharmacological interventions for bleeding reduction during open and minimally invasive myomectomy. Design: Systematic review and network meta-analysis of randomized controlled trials (RCTs). Setting: Not applicable. Patients: Trials assessing efficacy of pharmacological interventions during different types of myomectomy. Interventions: Misoprostol, oxytocin, vasopressin, tranexamic acid (TXA), epinephrine, or ascorbic acid. Main Outcome Measures: Intraoperative blood loss and need for blood transfusion. Results: The present review included 26 randomized control trials (RCTs) (N ¼ 1627). For minimally invasive procedures (9 RCTs; 474 patients), network meta-analysis showed that oxytocin (mean difference [MD] À175.5 mL, 95% confidence interval [CI] À30.1.07, À49.93), ornipressin (MD À149.6 mL, 95% CI À 178.22, À120.98), misoprostol, bupivacaine plus epinephrine, and vasopressin were effective in reducing myomectomy blood loss, but the evidence is of low quality. Ranking score of treatments included in subgroup analysis of minimally invasive myomectomy showed that oxytocin ranked first in reducing blood loss, followed by ornipressin. For open myomectomy (17 RCTs; 1,153 patients), network meta-analysis showed that vasopressin plus misoprostol (MD À652.97 mL, 95% CI À 1113.69, À174.26), oxytocin, TXA, and misoprostol were effective; however, the evidence is of low quality. Vasopressin plus misoprostol ranked first in reducing blood loss during open myomectomy (P ¼ .97). Conclusion:There is low-quality evidence to support uterotonics, especially oxytocin, and peripheral vasoconstrictors as effective options in reducing blood loss and need for blood transfusion during minimally invasive myomectomy. Oxytocin is the most effective intervention in minimally invasive myomectomy. For open myomectomy, a combination of uterotonics and peripheral vasoconstrictors is needed to effectively reduce blood loss. (Fertil Steril Ò 2020;113:224-33. Ó2019 by American Society for Reproductive Medicine.) El resumen está disponible en Español al final del artículo.

Vitamins and Uterine Fibroids: Current Data on Pathophysiology and Possible Clinical Relevance

“…The authors found that the operating time and the decrease in hemoglobin concentration were similar in both the study and control groups [99]. Samy et al (2020) studied anti-hemorrhagic agents during myomectomy and found that ascorbic acid and a combination of epinephrine plus bupivacaine were the least effective pharmacological options in this indication [100]. Interestingly, endometrial thinning was effectively treated with vitamins C and E in an infertile woman undergoing myomectomy.…”

“…Examples of using vitamin C and its analogs and derivatives are found in dermatology [198], and therefore some data could be referred to regarding this discussed matter. It ha been demonstrated that the use of vitamin C in the treatment of intraoperative bleeding was rather experimental and presented no considerable clinical effect [100].…”

Uterine Evacuation before Operative Hysteroscopy in Patients with Active Uterine Bleeding: A randomized controlled trial

“…However, operative hysteroscopy may be associated with complications such as uid overload, uterine perforation, and bleeding [8]. Several strategies have been used to facilitate the procedure and improve prognosis [9][10][11]. There is evidence on using gonadotropin agonists [12,13] and letrozole [14] as a preoperative intervention.…”

Uterine Evacuation before Operative Hysteroscopy in Patients with Active Uterine Bleeding: A randomized controlled trial

“…However, operative hysteroscopy may be associated with some complications such as fluid overload, bleeding, and uterine perforation [8]. Several strategies have been used to facilitate the procedure and improve the prognosis [9][10][11]. There is evidence on using gonadotropin agonists [12,13] and letrozole [14] as a preoperative intervention.…”