Interventions to reduce haemorrhage during myomectomy for fibroids
Editorial Group: Cochrane Menstrual Disorders and Subfertility Group
Published Online: 15 AUG 2014
Assessed as up-to-date: 17 JUN 2014
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Kongnyuy EJ, Wiysonge CS. Interventions to reduce haemorrhage during myomectomy for fibroids. Cochrane Database of Systematic Reviews 2014, Issue 8. Art. No.: CD005355. DOI: 10.1002/14651858.CD005355.pub5.
- Publication Status: New search for studies and content updated (conclusions changed)
- Published Online: 15 AUG 2014
Benign smooth muscle tumours of the uterus, known as fibroids or myomas, are often symptomless. However, about one-third of women with fibroids will present with symptoms that are severe enough to warrant treatment. The standard treatment of symptomatic fibroids is hysterectomy (that is surgical removal of the uterus) for women who have completed childbearing, and myomectomy for women who desire future childbearing or simply want to preserve their uterus. Myomectomy, the surgical removal of myomas, can be associated with life-threatening bleeding. Excessive bleeding can necessitate emergency blood transfusion. Knowledge of the effectiveness of the interventions to reduce bleeding during myomectomy is essential to enable evidence-based clinical decisions. This is an update of the review published in The Cochrane Library (2011, Issue 11).
To assess the effectiveness, safety, tolerability and costs of interventions to reduce blood loss during myomectomy.
In June 2014, we conducted electronic searches in the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL and PsycINFO, and trial registers for ongoing and registered trials.
We selected randomised controlled trials (RCTs) that compared potential interventions to reduce blood loss during myomectomy to placebo or no treatment.
Data collection and analysis
The two authors independently selected RCTs for inclusion, assessed the risk of bias and extracted data from the included RCTs. The primary review outcomes were blood loss and need for blood transfusion. We expressed study results as mean differences (MD) for continuous data and odds ratios for dichotomous data, with 95% confidence intervals (CI). We assessed the quality of evidence using GRADE methods.
Eighteen RCTs with 1250 participants met our inclusion criteria. The studies were conducted in hospital settings in low, middle and high income countries.
We found significant reductions in blood loss with the following interventions:
vaginal misoprostol (2 RCTs, 89 women: MD -97.88 ml, 95% CI -125.52 to -70.24; I
We found evidence of significant reductions in blood loss with a polyglactin suture (1 RCT, 28 women: MD -1870.0 ml, 95% CI -2547.16 to 1192.84) or a Foley catheter (1 RCT, 93 women: MD -240.70 ml, 95% CI -359.61 to -121.79) tied around the cervix. However, pooling data from these peri-cervical tourniquet RCTs revealed significant heterogeneity of the effects (2 RCTs, 121 women: MD (random) -1019.85 ml, 95% CI -2615.02 to 575.32; I
There was no good evidence of an effect on blood loss with oxytocin, morcellation or clipping of the uterine artery.
Need for blood transfusion
We found significant reductions in the need for blood transfusion with vasopressin (2 RCTs, 90 women: OR 0.15, 95% CI 0.03 to 0.74; I
There were insufficient data on the adverse effects and costs of the different interventions.
At present there is moderate-quality evidence that misoprostol may reduce bleeding during myomectomy, and low-quality evidence that bupivacaine plus epinephrine, tranexamic acid, gelatin-thrombin matrix, a peri-cervical tourniquet, ascorbic acid, dinoprostone, loop ligation and a fibrin sealant patch may reduce bleeding during myomectomy. There is no evidence that oxytocin, morcellation and temporary clipping of the uterine artery reduce blood loss. Further well designed studies are required to establish the effectiveness, safety and costs of different interventions for reducing blood loss during myomectomy.
Plain language summary
Interventions to reduce haemorrhage during myomectomy for treating fibroids
Some women have non-cancerous growths of the uterus, called fibroids. In a third of cases the fibroids produce symptoms, such as vaginal bleeding, that warrant treatment. The surgical removal of the fibroids, called myomectomy, is one of the treatment options for fibroids. It can be accomplished by either laparotomy (through an incision into the abdomen) or laparoscopy (keyhole surgery). The procedure is associated with heavy bleeding. Many interventions have been used by doctors to reduce bleeding during an operation for removing fibroids but it is unclear whether or not the interventions are effective.
The evidence is current to June 2014. The review included 18 studies with a total of 1250 women who had myomectomy for uterine fibroids. All studies compared an intervention to reduce bleeding during myomectomy with either a placebo or no such treatment.
The data available suggest that vaginal insertion of misoprostol and infiltration of vasopressin into the uterine muscle are effective in reducing bleeding during myomectomy. Limited data available also suggest that chemical dissection (such as with mesna), vaginal insertion of dinoprostone, a gelatin-thrombin matrix, tranexamic acid, infusion of vitamin C (ascorbic acid) during surgery, infiltration of a mixture of bupivacaine and epinephrine into the uterine muscles, or the use of fibrin sealant patch (a surgical patch that improves blood clotting) may be effective in reducing bleeding during myomectomy. We found limited information on the harms (adverse effects) of the different interventions.
Quality of the evidence
There is moderate-quality evidence that misoprostol reduces blood loss by between 70.24 ml and 125.52 ml; with a laparotomy vasopressin reduces blood loss by between 392.51 and 507.49 ml during myomectomy, and by between 121.73 ml and 172.17 ml during laparoscopic myomectomy. There is low-quality evidence for the rest of the interventions (chemical dissection, dinoprostone, gelatin-thrombin matrix, tranexamic acid, vitamin C, mixture of bupivacaine and epinephrine and a fibrin sealant patch).
Postupci za smanjenje krvarenja tijekom kirurškog uklanjanja mioma
Neke žene imaju u maternici dobroćudne izrasline koje nisu karcinomi, a zovu se miomi ili fibroidi. U trećini slučajeva takvi tumori uzrokuju simptome kao što su vaginalno krvarenje i stoga je nužno liječenje. Kirurško uklanjanje mioma (miomektomija) jedna je od mogućnosti liječenja. Može se napraviti laparotomijom (rezanjem stijenke trbuha) ili laparoskopijom (minimalno invazivnom kirurgijom koja na stijenci trbuha ostavlja nekoliko vrlo malih rezova). Kod tog se kirurškog postupka tipično javlja obilno krvarenje. Liječnici koriste mnoge postupke kako bi smanjili krvarenje tijekom miomektomije, ali nije jasno jesu li ti postupci učinkoviti.
Dokazi u ovom sustavnom pregledu odnose se na studije objavljene do srpnja 2014. godine. Sustavni pregled uključio je 18 studija s ukupno 1250 žena koje su podvrgnute miomektomiji zbog mioma (fibroida) maternice. Sve su studije usporedile postupke za smanjenje krvarenje tijekom miomektomije s placebom ili nikakvim dodatnim postupkom.
Dostupni podatci pokazuju da umetanje mizoprostola u vaginu i ubrizgavanje vazopresina u mišić maternice može učinkovito smanjiti krvarenje tijekom miomektomije. Ograničeni podatci također pokazuju da kemijska disekcija, vaginalno umetanje dinoprostona, korištenje želatinoznog matriksa koji sadrži trombin, traneksaminska kiselina, infuzija vitamina C tijekom kirurgije, ubizgavanje mješavine bupivakaina i adrenalina u mišiće maternice i korištenje naljepka s fibrinom (kirurški naljepak koji poboljšava zgrušavanje krvi) mogu biti učinkoviti u smanjenju krvarenja tijekom miomektomije. Pronađene su ograničene informacije o nuspojavama različitih istraženih postupaka.
Dokazi umjerene kvalitete pokazuju da mizoprostol smanjuje gubitak krvi između 70,24 i 125,52 ml. Vazopresin tijekom laparotomije smanjuje gubitak krvi između 392,51 i 507,49 ml, a tijekom laparoskopske miomektomije smanjuje gubitak krvi između 121,73 ml i 172,17 ml. O učinkovitosti ostalih istraživanih postupaka (kemijska disekcija, dinoproston, želatinozni matriksa koji sadrži trombin, traneksaminska kiselina, vitamin C, ubizgavanje mješavine bupivakaina i adrenalina, naljepak s fibrinom) trenutno su nam dostupni samo dokazi niske kvalitete.
Hrvatski Cochrane ogranak
Prevela: Livia Puljak