What are ways to minimize blood loss in uterine fibroids (myoma)?

Minimizing Blood Loss in Uterine Fibroids (Myoma)

The most effective strategies to minimize blood loss in myoma include myometrial injection of vasopressin during myomectomy, application of tourniquets on vascular pedicles, and perioperative use of tranexamic acid for abdominal myomectomy. 1, 2

Preoperative Strategies

• Medical management to reduce fibroid size and vascularity:

  • GnRH agonists: Reduce fibroid volume by approximately 35% before surgery 1, 3
  • Selective progesterone receptor modulators (SPRMs): Ulipristal acetate can achieve 65-67% fibroid volume reduction 3
  • Mifepristone: Shows promising initial results for reducing uterine and myoma size 1

• Preoperative preparation:

  • Correction of anemia before surgery 1
  • Storage of autologous blood to avoid homologous transfusion 1
  • Appropriate imaging (ultrasound/MRI) to determine fibroid location and vascularity 1, 3

Intraoperative Strategies

Surgical Techniques

• Vasoconstrictive agents:

  • Myometrial injection of vasopressin to reduce blood loss during myomectomy 1
  • Caution: Monitor for postoperative bleeding after vasopressin effect wears off 1

• Mechanical methods:

  • Application of tourniquets on vascular pedicles 1
  • Careful attention to surgical technique to minimize blood loss 1
  • Intraoperative blood scavenger systems to recover and reuse lost blood 1

• Approach selection based on fibroid type:

  • Hysteroscopic resection for intracavitary and submucous fibroids 1
  • Laparoscopic/robotic approach for subserosal or intramural fibroids 3
  • Minimally invasive approaches when technically feasible 3

Pharmacological Interventions

• Tranexamic acid (TA):
  • For abdominal myomectomy: Reduces perioperative blood loss by mean difference of 213.1 mL intraoperatively and 56.3 mL postoperatively 4
  • Most effective for multiple fibroids in open myomectomy, reducing blood loss by 40% 2
  • Less effective for laparoscopic/robotic myomectomies 5
  • Not recommended for hysteroscopic myomectomy (may be inferior to oxytocin) 4

Alternative Interventions

• Uterine Artery Embolization (UAE):

  • Effective for reducing blood supply to fibroids 3
  • 94% short-term and 85% long-term symptom improvement 3
  • Higher reintervention rates (36%) compared to myomectomy (5%) 1
  • Less effective for fibroids >5 cm 1

• Laparoscopic Uterine Artery Occlusion (LUAO):

  • Less effective than UAE with higher symptom recurrence (48% vs 17%) 1
  • Not recommended as first-line treatment 3

Special Considerations

• Fertility preservation:

  • Myomectomy is preferred for women desiring future fertility 3
  • UAE may compromise fertility with reports of intrauterine necrosis in 43% of cases 1

• Adhesion prevention:

  • Confine incisions to anterior uterine surface when possible 1
  • Use adhesion prevention barriers (oxidized regenerated cellulose, polytetrafluoroethylene, or hyaluronic acid with carboxymethylcellulose) 1
  • Minimize surgical trauma to reduce adhesion formation 1

Pitfalls and Caveats

• Tranexamic acid shows mixed results - effective for open abdominal myomectomy but not consistently beneficial for laparoscopic/robotic approaches 5, 2, 4
• Vasopressin injection requires monitoring for rebound bleeding after its effect wears off 1
• Myomectomy during pregnancy or cesarean delivery carries significantly higher bleeding risk due to increased myometrial vascularity 1
• Before any minimally invasive therapy in postmenopausal women, rule out uterine sarcoma and endometrial cancer 3