ABSTRACT
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.
ABSTRACT
BACKGROUND: Interstitial cystitis (IC)/bladder pain syndrome (BPS) is an unpleasant sensation related to the bladder with lower urinary tract symptoms lasting more than 6 weeks, unrelated to an otherwise identifiable cause. The etiology is likely multifactorial including urothelial abnormalities, neurogenic pain upregulation, and potentially bladder and vaginal microbiome alterations. Despite treatment effectiveness of both bladder instillations and intradetrusor onabotulinumtoxinA injection for this condition, a head-to-head comparison has not been performed. OBJECTIVE: To compare the efficacy of bladder instillations and intradetrusor onabotulinumtoxinA injection for treatment of IC/BPS. STUDY DESIGN: Patients with O'Leary-Sant (OLS) questionnaire scores of ≥6, meeting clinical criteria for IC/BPS, and desiring procedural management were randomized to bladder instillations or intradetrusor onabotulinumtoxinA injection. The primary outcome was the difference in OLS scores at 2 months posttreatment between groups. Secondary outcomes included evaluation of sexual function, physical/mental health status, pain, patient satisfaction, treatment perception, retreatment, and adverse event rates. RESULTS: Forty-seven patients were analyzed with 22 randomized to bladder instillations and 25 to onabotulinumtoxinA injection. There were no differences in demographic and clinical characteristics between groups. From baseline to 2 months posttreatment, there was a decrease in OLS subscales in all patients (Interstitial Cystitis Symptom Index [ICSI] -6.3 (confidence interval [CI] -8.54, -3.95), P<.0001; Interstitial Cystitis Problem Index [ICPI] -5.9 (CI -8.18, -3.57), P<.0001). At 2 months posttreatment, patients in the onabotulinumtoxinA group had significantly lower OLS scores compared to those in the bladder instillation group (ICSI 6.3±4.5 [onabotulinumtoxinA] vs 9.6±4.2 [instillation], P=.008; ICPI 5.9±5.1 [onabotulinumtoxinA] vs 8.3±4.0 [instillation], P=.048). The difference in OLS scores between groups did not persist at 6 to 9 months posttreatment. There were no statistically significant differences between baseline and posttreatment time points for the remaining questionnaires. Eight percent of patients who received onabotulinumtoxinA injection experienced urinary retention requiring self-catheterization. Patients who underwent onabotulinumtoxinA injection were significantly less likely to receive retreatment within 6 to 9 months compared to patients who received bladder instillations (relative risk 13.6; 95% CI, 1.92-96.6; P=.0002). There were no differences between groups regarding patient satisfaction, perception of treatment convenience, or willingness to undergo retreatment. CONCLUSION: Both onabotulinumtoxinA injection and bladder instillations are safe, effective treatments for patients with IC/BPS, with significant clinical improvement demonstrated at 2 months posttreatment. Our findings suggest that intradetrusor onabotulinumtoxinA injection is a more effective procedural treatment for this condition than bladder instillation therapy and associated with decreased rates of retreatment.