Perioperative nonhormonal pharmacological interventions for bleeding reduction during open and minimally invasive myomectomy: a systematic review and network meta-analysis

Uterotonics and peripheral vasoconstrictors during minimally invasive myomectomy and combination of different interventions during open myomectomy were the best options to effectively reduce myomectomy blood loss.

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Volume 113, Issue 1, Pages 224–233.e6


Ahmed Samy, M.D., Ayman N. Raslan, M.D., Bassem Talaat, M.D., Ahmed El Lithy, M.D., Mohamed El Sharkawy, M.D., Marwa Fouad Sharaf, M.D., Amr Hassan Hussein, M.D., Ahmed Hussein Amin, M.D., Ahmed M. Ibrahim, M.D., Wael Sayed Elsherbiny, M.D., Hossam H. Soliman, M.D., Ahmed A. Metwally, M.D.



To synthesize evidence on the most effective pharmacological interventions for bleeding reduction during open and minimally invasive myomectomy.


Systematic review and network meta-analysis of randomized controlled trials (RCTs).


Not applicable.


Trials assessing efficacy of pharmacological interventions during different types of myomectomy.


Misoprostol, oxytocin, vasopressin, tranexamic acid (TXA), epinephrine, or ascorbic acid.

Main Outcome Measures

Intraoperative blood loss and need for blood transfusion.


The present review included 26 randomized control trials (RCTs) (N = 1627). For minimally invasive procedures (9 RCTs; 474 patients), network meta-analysis showed that oxytocin (mean difference [MD] −175.5 mL, 95% confidence interval [CI] −30.1.07, −49.93), ornipressin (MD −149.6 mL, 95% CI − 178.22, −120.98), misoprostol, bupivacaine plus epinephrine, and vasopressin were effective in reducing myomectomy blood loss, but the evidence is of low quality. Ranking score of treatments included in subgroup analysis of minimally invasive myomectomy showed that oxytocin ranked first in reducing blood loss, followed by ornipressin. For open myomectomy (17 RCTs; 1,153 patients), network meta-analysis showed that vasopressin plus misoprostol (MD −652.97 mL, 95% CI − 1113.69, −174.26), oxytocin, TXA, and misoprostol were effective; however, the evidence is of low quality. Vasopressin plus misoprostol ranked first in reducing blood loss during open myomectomy (P = .97).


There is low-quality evidence to support uterotonics, especially oxytocin, and peripheral vasoconstrictors as effective options in reducing blood loss and need for blood transfusion during minimally invasive myomectomy. Oxytocin is the most effective intervention in minimally invasive myomectomy. For open myomectomy, a combination of uterotonics and peripheral vasoconstrictors is needed to effectively reduce blood loss.

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Fertility and Sterility

Editorial Office, American Society for Reproductive Medicine

Fertility and Sterility® is an international journal for obstetricians, gynecologists, reproductive endocrinologists, urologists, basic scientists and others who treat and investigate problems of infertility and human reproductive disorders. The journal publishes juried original scientific articles in clinical and laboratory research relevant to reproductive endocrinology, urology, andrology, physiology, immunology, genetics, contraception, and menopause. Fertility and Sterility® encourages and supports meaningful basic and clinical research, and facilitates and promotes excellence in professional education, in the field of reproductive medicine.