Efficacy of pharmacologic hemorrhage prophylactics in second-trimester abortions: a systematic review

OBJECTIVE: This study aimed to evaluate prophylactic uterotonics, antifibrinolytic medications, and vasoconstrictive agents in the prevention of hemorrhage during second-trimester abortions. DATA SOURCES: PubMed, Embase (Elsevier platform), Evidence-Based Medicine Reviews (Ovid platform), and Web of Science were searched from database creation to October 30, 2023. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials, cohort studies, case- control studies, and case series evaluating pregnant individuals (between 13 0/7 and 27 6/7 weeks of gestation) who underwent dilation and evacuation and received prophylactic uterotonics (methylergonovine, carboprost, oxytocin, or misoprostol), antifibrinolytic medications (tranexamic acid), or vasoconstrictive agents (vasopressin, lidocaine with epinephrine) were included in the study. The outcomes of interest included postprocedural bleeding, rate of medications to treat bleeding, blood transfusion, reoperation, and transfer to a higher level of care for hemorrhage. METHODS: Of note, 2 authors independently screened the abstracts using the Systematic Review Data Repository. A third reviewer resolved discrepancies. The full text of accepted abstracts was retrieved and assessed for eligibility by 2 independent authors. Eligible studies were independently assessed for quality and bias by 3 authors. A consensus review resolved discrepancies. RESULTS: Among 5834 abstracts screened, 11 studies met the inclusion criteria: 5 randomized controlled trials, 3 retrospective cohort studies, and 3 case series, totaling 3857 individuals. The paucity of studies combined with the heterogeneity of included trials precluded the performance of the meta-analysis. Of note, 4 studies evaluating misoprostol were of overall low-quality evidence and primarily assessed misoprostol's use for cervical dilation. Thus, its efficacy in bleeding prophylaxis remains unclear. Moreover, 2 high-quality trials evaluating oxytocin concluded that oxytocin use resulted in decreased blood loss, without a difference in interventions to control bleeding. Furthermore, 2 studies provided moderate-quality evidence that paracervical vasopressin use decreased blood loss, particularly at advanced gestational ages, but subsequent intervention outcomes were not assessed. High-quality evidence evaluating methylergonovine found that this medication increased blood loss at the time of the procedure. CONCLUSION: Current evidence on hemorrhage prophylaxis at the time of dilation and evacuation supports the 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 on outcomes by gestational age can identify subgroups with the potential to derive the most benefit.