Does Tranexamic Acid Reduce Blood Loss During Myomectomy?

BACKGROUND AND PURPOSE:

• Fusca et al. (Journal of Obstetrics and Gynaecology Canada, 2018) assessed the effectiveness of tranexamic acid (TXA) in reducing perioperative blood loss during myomectomy

METHODS:

• Systematic review and meta-analysis
  • Women of reproductive age with uterine fibroids undergoing myomectomy (abdominal, laparoscopic, robotic, or hysteroscopic)
• Included RCTs that assessed
  • TXA vs
  • Comparator
    • Placebo | No treatment | Another active comparator
• Primary outcomes
  • Perioperative blood loss or
  • Transfusion

RESULTS:

• 4 RCTS | 313 women undergoing myomectomy
  • 3 studies: Abdominal myomectomy
  • 1 study: Hysteroscopic myomectomy
• Compared to placebo or no intervention, TXA significantly reduced
  •  Intraoperative blood loss (abdominal): Mean difference 213.1 mL (95% CI, -242.4 to -183.7)
    • Above results from abdominal hysterectomy because no intraoperative blood loss was reported for the 1 hysteroscopic myomectomy
  • Postoperative blood loss (abdominal): Mean difference 56.3 mL (95% CI, -67.8 to -44.8)
• Blood transfusion
  • No significant differences between groups in blood transfusion requirement
  • Relative risk 0.58 (95% CI, 0.33-1.00)
• Hysteroscopic myomectomy
  • TXA not associated with improved outcomes for reduced postoperative hemoglobin levels compared with oxytocin
    • 10.18 vs 11.13 g/dL (p<0.001)

CONCLUSION:

• TXA reduces perioperative blood loss in women undergoing abdominal myomectomy but no impact was seen in women undergoing hysteroscopic myomectomy
• Studies looking at TXA for laparoscopic or robotic myomectomy were not found
  • Authors note that blood loss is significantly lower with minimally invasive surgical myomectomy approach
  • Benefit of TXA may therefore be limited in minimally invasive surgery for myomectomy

Learn More – Primary Sources:

The Effectiveness of Tranexamic Acid at Reducing Blood Loss and Transfusion Requirement for Women Undergoing Myomectomy: A Systematic Review and Meta-analysis.

Postpartum Hemorrhage Prophylaxis: The World Health Organization Recommendations

SUMMARY:

Uterotonics for PPH prophylaxis are administered immediately prior to or after placental delivery. The World Health Organization (WHO), based on an extensive review, has provided guidance on the efficacy and safety of uterotonics for the prevention of PPH. In addition, the WHO recommendations provide evidence-based guidelines on the drugs of choice. These recommendations apply to both vaginal and cesarean delivery.

KEY POINTS:

Efficacy and Safety

• Only one of the following uterotonics should be used for PPH prophylaxis
  • Oxytocin | Carbetocin | Misoprostol | Ergometrine/methylergometrine | Oxytocin and ergometrine fixed-dose combination
• Oxytocin 10 IU IM/IV
  • Recommended for all births
  • Requires refrigerated transport and storage (2–8 °C)
    • Consider another uterotonic if refrigeration cannot be guaranteed
  • Carbetocin 100 µg IM/IV
    • Recommended for all births
    • Heat-stable carbetocin does not require refrigeration
    • Note: Recommendation is ‘context specific’ and applies in settings where cost is comparable to other effective uterotonics
  • Misoprostol 400 µg or 600 µg PO
    • Recommended for all births
    • Different routes of administration are available aside from oral (buccal, sublingual, rectal)
      • Choice of PO based on women’s preference
    • Counsel patients about possible adverse side effects such as shivering, fever and diarrhea
  • Ergometrine/methylergometrine 200 µg IM/IV
    • Recommended for PPH prevention
    • Requires refrigeration
    • Note: Recommendation is ‘context specific’ in settings where hypertensive disorders can be safely excluded prior to administration
  • Oxytocin and ergometrine fixed dose combination 5 IU/500 µg IM
    • Recommended for PPH prevention
    • Requires refrigeration
    • Note: Recommendation is ‘context specific’ in settings where hypertensive disorders can be safely excluded prior to administration
  • Carboprost or sulprostone (injectable prostaglandins)
    • Not recommended

Choice of Uterotonic

• Oxytocin 10 IU IM/IV is the primary recommended uterotonic agent for all births, when there is choice of uterotonics
• If oxytocin is not available or quality “cannot be guaranteed”
  • Other acceptable uterotonics listed above are recommended
• If injectable uterotonics cannot be used due to lack of skilled personnel
  • WHO recommends that community and lay health workers can administer oral misoprostol (400 µg or 600 µg)

Learn More – Primary Sources:

WHO recommendations Uterotonics for the prevention of postpartum haemorrhage

Uterotonic agents for preventing postpartum haemorrhage: a network meta‐analysis