<div>Leiomyomata are common benign pelvic masses that occur in up to 77% of
reproductive aged women (Flyckt et al Clin Obstet Gynecol
2017;60(2):252-272). Myomectomies are frequently performed for
symptomatic leiomyoma unresponsive to non-surgical treatments and can be
performed via laparotomy (open) or minimally invasive approaches. Open
myomectomies are often performed because of lack of access to or
training with minimally invasive approaches, or secondary to concerns
surrounding morcellation.</div><div>Misoprostol is a relatively inexpensive readily accessible uterotonic
and vasoconstrictive medication. Based on mechanism of action,
misoprostol is often used at the time of myomectomy to decrease blood
loss. This led Wali et al. (Wali et al BJOG 2020 xxxx) to perform a
systematic review on the effectiveness of preoperative misoprostol
specifically at the time of open myomectomy. Eight randomized-controlled
trials met inclusion criteria and were included in this systematic
review with a total of 385 participants, 192 in the misoprostol group
193 in the control group.</div><div>These studies provide moderate to high quality evidence on the following
six outcomes: 1) estimated blood loss, 2) drop in haemoglobin, 3) need
for blood transfusion, 4) operative time, 5) post-operative fever, and
6) length of hospital stay. The specific findings for those six outcomes
are as follows. Compared to placebo, misoprostol significantly reduced
estimated blood loss by a mean of 170cc with an associated haemoglobin
decrease of 0.48 g/dL. Perhaps the most clinically significant finding
was that preoperative misoprostol led to a three-fold lower risk of
blood transfusion with an odds-ratio of 0.31. The use of preoperative
misoprostol also led to a decreased operative time of 11 minutes, which
is probably clinically significant based on the relative low expense of
misoprostol and relative high cost of time in the operating theater.
There was no statistically significant difference in the rates of
postoperative fever or length of hospital stay. Patients in the
misoprostol group were discharged an average of 3.5 hours earlier than
the placebo group which is probably not clinically significant.</div><div>Based on the overall risk-benefit profile identified in this study, it
would seem that preoperative misoprostol should be recommended for most
patients prior to open myomectomy. The findings from this systematic
review are particularly important for low-resource settings where access
to minimally invasive approaches and the availability of blood for
possible transfusion are limited. Although there was variability in the
timing and the dose of preoperative misoprostol, Wali et al (Wali et al
BJOG 2020 xxxx) suggest the evidence supports a single dose of 400μg of
misoprostol 30 to 60 minutes prior to surgery, or two doses 3 hours
apart. A protocol of one dose of misoprostol 30 minutes prior to taking
a patient to the operating theater could be implemented as part of a
standard preoperative order set and administered in the pre-anesthesia
care unit. This study highlights a simple, low-cost intervention that
can significantly improve patient outcomes.</div><div><b>Disclosure of interest:</b> None to declare. A completed disclosure
of interest form is available to view online as supporting information.</div>