Tranexamic acid in gynecologic surgery

Abstract

Objective: To review the mechanism of action, pharmacology, dosing, and complications of tranexamic acid (TXA) and consolidate current evidence for TXA in gynecologic surgery.

Methods: A literature search of PubMed, Ovid (MEDLINE), Google Scholar, and Elsevier was performed, in addition to a targeted search of cited references involving TXA and gynecologic surgery. Preference was given to systematic reviews and randomized control trials (RCTs).

Results: TXA reversibly binds to plasminogen, preventing clot degradation. RCTs on hysterectomy, myomectomy, cervical conisation, hysteroscopy, and surgery for cervical and ovarian cancer were identified, as were case reports on TXA use for ectopic pregnancy. During hysterectomy, TXA reduces blood loss (two RCTs, n = 432, mean difference –66.0 mL and 180 mL), blood transfusion (1 RCT, n = 100, 12% vs. 42%, p < .00001). For myomectomy, a systematic review and meta-analysis showed a statistically significant decrease in blood loss with TXA (two RCTs, mean difference –213.1 mL, 95% CI: –242.4 mL to –183.7 mL). Following cervical conisation, TXA decreased the risk of delayed hemorrhage (four RCTs, RR 0.23, 95% CI: 0.11–0.50). A single RCT for cervical and ovarian cancer surgery demonstrated a decrease mean blood loss of 120 mL–135 mL and 210 mL, respectively, and fewer blood transfusions for the latter (OR 0.44, upper 95% CI: 0.97, p = .02). Less robust data suggest a possible benefit from TXA during hysteroscopy and surgery for ectopic pregnancies. Most commonly, 1 g of intravenous TXA is given intraoperatively.

Conclusion: TXA is a safe adjunct that can be considered in a variety of gynecologic surgeries to decrease blood loss and risk of blood transfusion.

Keywords:

• Blood loss
• hysterectomy
• myomectomy
• surgery
• tranexamic acid

Transparency

Declaration of funding

No potential conflict of interest was reported by the authors.

Declaration of financial/other relationships

AZ has received honoraria from Hologic. APS is a consultant and on the speaker bureau for Hologic and is a consultant for Medtronic. MJS is a consultant for Medtronic and sits on the advisory board of Abbvie, Allergan, and FelixForYou. Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Author contributions

All authors agree to be accountable for all aspects of the work. AZ: design, literature review, manuscript preparation. APS: conception and design, literature review, manuscript preparation. MJS: manuscript preparation.

Acknowledgements

No assistance in the preparation of this article is to be declared.

Previous presentations

This article has been presented in abstract form at the 2019 ACSC conference in Halifax, Canada, and as a virtual poster at the 2019 CanSAGE4 conference in Ottawa, Canada.