Intervention Review

Interventions to reduce haemorrhage during myomectomy for fibroids

  1. Eugene J Kongnyuy1,*,
  2. Charles Shey Wiysonge2,3

Editorial Group: Cochrane Menstrual Disorders and Subfertility Group

Published Online: 15 AUG 2014

Assessed as up-to-date: 17 JUN 2014

DOI: 10.1002/14651858.CD005355.pub5


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.

Author Information

  1. 1

    Reproductive Health Solutions, Salisbury, UK

  2. 2

    Stellenbosch University, Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Cape Town, South Africa

  3. 3

    Stellenbosch University, Division of Community Health, Faculty of Medicine and Health Sciences, Cape Town, South Africa

*Eugene J Kongnyuy, Reproductive Health Solutions, 43 Fowler's Rd, Salisbury, SP1 2QP, UK. kongnyuy73@yahoo.com.

Publication History

  1. Publication Status: New search for studies and content updated (conclusions changed)
  2. Published Online: 15 AUG 2014

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. Laički sažetak

Background

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).

Objectives

To assess the effectiveness, safety, tolerability and costs of interventions to reduce blood loss during myomectomy.

Search methods

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.

Selection criteria

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.

Main results

Eighteen RCTs with 1250 participants met our inclusion criteria. The studies were conducted in hospital settings in low, middle and high income countries.

Blood loss
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; I2 = 43%; moderate-quality evidence); intramyometrial vasopressin (3 RCTs, 128 women: MD -245.87 ml, 95% CI -434.58 to -57.16; I2 = 98%; moderate-quality evidence); intramyometrial bupivacaine plus epinephrine (1 RCT, 60 women: MD -68.60 ml, 95% CI -93.69 to -43.51; low-quality evidence); intravenous tranexamic acid (1 RCT, 100 women: MD -243 ml, 95% CI -460.02 to -25.98; low-quality evidence); gelatin-thrombin matrix (1 RCT, 50 women: MD -545.00 ml, 95% CI -593.26 to -496.74; low-quality evidence); intravenous ascorbic acid (1 RCT, 102 women: MD -411.46 ml, 95% CI -502.58 to -320.34; low-quality evidence); vaginal dinoprostone (1 RCT, 108 women: MD -131.60 ml, 95% CI -253.42 to -9.78; low-quality evidence); loop ligation of the myoma pseudocapsule (1 RCT, 70 women: MD -305.01 ml, 95% CI -354.83 to -255.19; low-quality evidence); and a fibrin sealant patch (1 RCT, 70 women: MD -26.50 ml, 95% CI -44.47 to -8.53; low-quality evidence).
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; I2 = 95%; low-quality evidence).
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; I2 = 0%; moderate-quality evidence); peri-cervical tourniquet (2 RCTs, 121 women: OR 0.09, 95% CI 0.01 to 0.84; I2 = 69%; low-quality evidence); gelatin-thrombin matrix (1 RCT, 100 women: OR 0.01, 95% CI 0.00 to 0.10; low-quality evidence) and dinoprostone (1 RCT, 108 women: OR 0.17, 95% CI 0.04 to 0.81; low-quality evidence), but no evidence of effect on the need for blood transfusion with misoprostol, oxytocin, tranexamic acid, ascorbic acid, loop ligation of the myoma pseudocapsule and a fibrin sealant patch.

There were insufficient data on the adverse effects and costs of the different interventions.

Authors' conclusions

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

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. Laički sažetak

Interventions to reduce haemorrhage during myomectomy for treating fibroids

Background

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.

Study characteristics

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.

Key results

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).

 

Laički sažetak

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. Laički sažetak

Postupci za smanjenje krvarenja tijekom kirurškog uklanjanja mioma

Dosadašnje spoznaje

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.

Značajke istraživanja

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.

Glavni rezultati

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.

Kvaliteta dokaza

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.

Bilješke prijevoda

Hrvatski Cochrane ogranak
Prevela: Livia Puljak