RESUMO
OBJECTIVE: To evaluate prophylactic uterotonics, antifibrinolytic medications, and vasoconstrictive agents in prevention of hemorrhage during second trimester abortions. DATA SOURCES: PubMed, EMBASE (Elsevier platform), EBM reviews (Ovid platform), and Web of Science were searched from database creation to October 30th, 2023. STUDY ELIGIBILITY CRITERIA: Randomized control trials, cohort studies, case-control studies, and case series evaluating pregnant individuals (between 13 weeks gestation and 27 weeks, 6 days gestation) undergoing dilation and evacuation who received prophylactic uterotonics (methylergonovine, carboprost, oxytocin, misoprostol), antifibrinolytic medications (tranexamic acid), or vasoconstrictive agents (vasopressin, lidocaine with epinephrine). Outcomes of interest included post-procedural bleeding, rate of medications to treat bleeding, blood transfusion, re-operation, or transfer to a higher level of care for hemorrhage. STUDY APPRAISAL AND SYNTHESIS METHODS: Two authors independently screened abstracts using the Systematic Review Data Repository. A third reviewer resolved discrepancies. Full text of accepted abstracts were retrieved and assessed for eligibility by two independent authors. Eligible studies were independently assessed for quality and bias by three authors. Consensus review resolved discrepancies. RESULTS: Among 5,834 abstracts screened, 11 studies met inclusion criteria: five randomized control trials, three retrospective cohort studies, and three case series, totaling 3,857 individuals. The paucity of studies combined with the heterogeneity of included trials precluded performance of a metanalysis. Four studies evaluating misoprostol were of overall low-quality evidence and primarily assessed misoprostol's use for cervical dilation, thus its efficacy for bleeding prophylaxis remains unclear. Two high quality trials evaluating oxytocin concluded that oxytocin use resulted in decreased blood loss, without difference in interventions to control bleeding. Two studies provided moderate quality evidence that paracervical vasopressin use decreased blood loss, particularly at advanced gestational ages, but subsequent intervention outcomes were not assessed. The high quality evidence evaluating methylergonovine found this medication increased blood loss at time of procedure. CONCLUSIONS: Current evidence for hemorrhage prophylaxis at time of dilation and evacuation supports use of intravenous oxytocin or paracervical vasopressin to decrease procedural blood loss, without an associated decrease in transfusion rate or use of other interventions. Future research into outcomes by gestational age can identify subgroups with potential to derive the most benefit.
RESUMO
INTRODUCTION: To determine whether progestin type or number of dilation and curettage procedures (D&Cs) were associated with intrauterine synechiae (IS) or pregnancy outcomes in patients conservatively treated for endometrial intraepithelial neoplasia (EIN) or endometrial cancer (EC). MATERIALS AND METHODS: We evaluated patients conservatively treated for EIN or EC from 2000 to 2017 at an academic center. IS were identified hysteroscopically. We calculated proportions for categorical variables and tested associations between D&C number, progestin, and pregnancy outcomes using Pearson chi-squared and Fisher's exact tests. A post-hoc power analysis indicated sufficient power to detect livebirth. RESULTS: We analyzed 54 patients, 15 with EIN (28 %) and 39 with EC (72 %), with a mean age of 34 ± 1.2 years. Progestin treatment types included megestrol acetate (MA) (n = 24), MA with levonorgestrel intrauterine device (LngIUD) (n = 10), MA followed by LngIUD (n = 3), and LngIUD alone (n = 6). Mean number of D&Cs was 3.9 ± 0.9. Overall, 53 subjects underwent hysteroscopy; 10 (19 %) had IS. When D&Cs were grouped into 0-2, 3-4 and ≥5, each increase in D&C group had a 2.9 higher odds of IS (OR: 2.91, p = 0.04, CI: 1.05-10.02). LngIUD was associated with a nonsignificant 46 % decrease in the odds of IS (OR: 0.54, p = 0.66, CI: 0.08-2.87). Twenty-two women attempted pregnancy; 14 women achieved a total of 20 pregnancies and 9 women had total of 15 livebirths (41 % livebirth rate). The number of D&Cs and progestin treatment type were not associated with pregnancy outcomes. DISCUSSION: Among 54 patients conservatively treated for EC/EIN, nearly 20 % developed IS. However, hysteroscopic and/or fertility treatments may improve pregnancy outcomes.