INTRODUCTION
Hysterectomy, despite a decline in the rates of effective conservative
management of benign uterine disease, is the most frequent gynecological
surgery and overall, second to the cesarean section in many parts of the
world [1]
[2]. The choice of the approach
depends on the surgeon’s preference, nature of the disease, the
indication of the surgery, and patient characteristics
[3]. Common medical indications of
hysterectomy include gynecological ailments such as fibroids,
dysfunctional uterine bleeding, uterine prolapse
[4], endometriosis, or chronic pelvic
pain. It may also be required for cases of acute menorrhagia refractory
to medical or conservative surgical treatment
[5]. In the United States, among women
aged 15 years and above who underwent hysterectomy during 2000–04,
uterine leiomyoma was the most common hysterectomy indication accounting
for nearly 41% of all hysterectomies
[1].
Hysterectomy can be a part of staging laparotomy or radical
hysterectomy. Rates of various complications with hysterectomy have been
reported from 0.5% to 43% [6].
Tranexamic acid (TXA) is a synthetic lysine analog that competitively
blocks the lysine-binding sites of plasminogen, plasmin, and tissue
plasminogen activator, thereby retarding fibrinolysis and blood clot
degradation. It may be administered orally, intravenously, or topically,
with a rapid onset of action (tmax = appx 3 hours) and 11-hour half-life
[7]. It is 6 to 10 times more potent
than aminocaproic acid, another commonly used synthetic
anti-fibrinolytic agent. Typical IV dosing is 10 mg/kg followed by
infusion of 1mg/kg/hour [8]. A dosage
of 10 to 15m/kg administered over 5 to 10 minutes before skin incision
can also be given [9]. Intravenous TXA
can cause hypotension (with rapid IV injection), dizziness, allergic
dermatitis, diarrhea, nausea, vomiting, and blurred vision
[10]. The CRASH-2 trial collaborators
randomized 20,211 adult trauma patients with significant bleeding or at
risk of significant bleeding within 8 hours of injury to IV tranexamic
acid or placebo [11]. Mortality was
significantly reduced with tranexamic acid (RR .91; p=.0035). Systematic
reviews were done in 2011, and 2012, of patients undergoing elective
surgery, showed that TXA administration reduced the risk of transfusion
perioperatively(RR.61).12,13
The use of oral TXA in the management of
acute and abnormal uterine bleeding has been reported and is
FDA-approved for the treatment of menorrhagia
[11]
[12]. One randomized study of oral
TXA in the treatment of ovulatory menorrhagia reported a 45% decrease
in mean menstrual blood loss using TXA compared with placebo
[14]. Oral administration of TXA in
cases undergoing conization of the cervix with the open surgical
technique has also been reported
[15]. In patients undergoing primary
debulking surgery for gynecologic cancers, the administration of IV TXA
has been shown to decrease intraoperative blood loss by 30% and reduce
the need for intraoperative blood transfusion
[16,17].
However, the role of IV tranexamic acid has not been effectively
evaluated in reducing blood loss during hysterectomies for benign
gynecological conditions, hence the need for this study.