Kongnyuy Eugene J, Wiysonge Charles Shey
United Nations Population Fund, New York, USA.
Cochrane Database Syst Rev. 2011 Nov 9(11):CD005355. doi: 10.1002/14651858.CD005355.pub4.
Uterine myomas (fibroids) are benign tumours of the uterus. Myomectomy, the surgical removal of myomas, can be associated with life-threatening bleeding and prolonged postoperative stay. 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 Issue 3, 2009.
To assess the effectiveness, safety, tolerability, and costs of interventions to reduce blood loss during myomectomy.
Electronic searches were undertaken in the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3), MEDLINE (1950 to February 2011), EMBASE (1980 to February 2011), CINAHL (1982 to February 2011), and PsycINFO (1801 to February 2011).
Only randomised controlled trials (RCTs) that compared the use of interventions to reduce blood loss during myomectomy to placebo or no treatment were included.
The two authors independently selected RCTs for inclusion, assessed the methodological quality of trials, and extracted data. We expressed study results as mean differences (MD) for continuous data and odds ratios for dichotomous data, with 95% confidence intervals (CI).
Twelve RCTs with 674 participants met our inclusion criteria. The interventions were intramyometrial vasopressin (two RCTs), intravenous oxytocin (two RCTs), peri-cervical tourniquet (two RCTs), and one RCT each for vaginal misoprostol, gelatin thrombin matrix, chemical dissection with sodium-2-mercaptoethane sulfonate (mesna), intramyometrial bupivacaine plus epinephrine, tranexamic acid, and myoma enucleation by morcellation. We found significant reductions in blood loss with misoprostol (MD -149.00 ml, 95% CI -229.24 to -68.76), vasopressin (MD -298.72 ml, 95% CI -593.10 to -4.34; I(2) = 99%), bupivacaine plus epinephrine (MD -68.60 ml, 95% CI -93.69 to - 43.51), tranexamic acid (MD -243 ml, 95% CI -460 to -25.98), peri-cervical tourniquet (MD -289.44, 95% CI -406.55 to -172.32; I(2) = 95%), and gelatin-thrombin matrix (MD -545.00 ml, 95% CI -593.26 to -496.74). There was no evidence of an effect on blood loss with oxytocin or morcellation. None of the interventions significantly increased myomectomy-related complications. The trials did not assess the costs of the different interventions.
AUTHORS' CONCLUSIONS: There is limited evidence that misoprostol, vasopressin, bupivacaine plus epinephrine, tranexamic acid, gelatin thrombin matrix, peri-cervical tourniquet, and mesna may reduce bleeding during myomectomy. Bupivacaine plus epinephrine has limited clinical importance compared with other interventions as the clinical impact was small. There is no evidence that oxytocin and morcellation reduce blood loss. Further well designed studies are required to establish effectiveness, safety and the costs of different interventions for reducing blood loss during myomectomy.
子宫肌瘤是子宫的良性肿瘤。子宫肌瘤剔除术，即手术切除肌瘤，可能会导致危及生命的出血以及术后住院时间延长。了解在子宫肌瘤剔除术中减少出血的干预措施的有效性对于做出基于证据的临床决策至关重要。这是对2009年第3期《 Cochr ane图书馆》发表的综述的更新。
评估在子宫肌瘤剔除术中减少失血的干预措施的有效性、安全性、耐受性和成本。
在Cochrane月经紊乱与生育力低下问题组专业注册库、Cochrane对照试验中心注册库（CENTRAL）（《Cochrane图书馆》2011年第3期）、MEDLINE（1950年至2011年2月）、EMBASE（1980年至2011年2月）、CINAHL（1982年至2011年2月）和PsycINFO（1801年至2011年2月）中进行了电子检索。
仅纳入比较在子宫肌瘤剔除术中使用减少失血的干预措施与安慰剂或不治疗的随机对照试验（RCT）。
两位作者独立选择纳入的RCT，评估试验的方法学质量，并提取数据。我们将研究结果表示为连续数据的平均差（MD）和二分数据的比值比，并给出95%置信区间（CI）。
12项RCT共674名参与者符合我们的纳入标准。干预措施包括肌层内注射血管加压素（2项RCT）、静脉注射缩宫素（2项RCT）、宫颈周围止血带（2项RCT），以及分别针对阴道米索前列醇、明胶凝血酶基质、2-巯基乙烷磺酸钠（美司钠）化学分离、肌层内布比卡因加肾上腺素、氨甲环酸和旋切法子宫肌瘤剔除术的各1项RCT。我们发现米索前列醇（MD -149.00 ml，95%CI -229.24至-68.76）、血管加压素（MD -298.72 ml，95%CI -593.10至-4.34；I² = 99%）、布比卡因加肾上腺素（MD -68.60 ml，95%CI -93.69至-43.51）、氨甲环酸（MD -243 ml，95%CI -460至-25.98）、宫颈周围止血带（MD -289.44，95%CI -406.55至-172.32；I² = 95%）和明胶凝血酶基质（MD -545.00 ml，95%CI -593.26至-496.74）可显著减少失血。没有证据表明缩宫素或旋切法对失血有影响。没有一种干预措施显著增加与子宫肌瘤剔除术相关的并发症。这些试验未评估不同干预措施的成本。
有有限的证据表明米索前列醇、血管加压素、布比卡因加肾上腺素、氨甲环酸、明胶凝血酶基质、宫颈周围止血带和美司钠可能会减少子宫肌瘤剔除术中的出血。与其他干预措施相比，布比卡因加肾上腺素的临床重要性有限，因为其临床影响较小。没有证据表明缩宫素和旋切法可减少失血。需要进一步设计良好的研究来确定不同干预措施在减少子宫肌瘤剔除术中失血方面的有效性、安全性和成本。
