# The Route of Misoprostol in Reducing Blood Loss for Transperitoneal Myomectomies: A Systematic Review and Meta-analysis

## TL;DR

Rectal misoprostol reduces blood loss more effectively than other methods during abdominal myomectomy surgeries.

## Contribution

This systematic review and meta-analysis identifies rectal administration of misoprostol as the most effective route for reducing intraoperative blood loss in myomectomies.

## Key findings

- Rectal misoprostol reduced blood loss by an average of 152.43 mL compared to other routes.
- Vaginal administration also reduced blood loss, but less effectively than rectal.
- Sublingual administration showed no statistically significant reduction in blood loss.

## Abstract

Rectal misoprostol is associated with reduced blood loss in transperitoneal myomectomies compared to other modes of administration.

To compare the efficacy of different routes of misoprostol administration (sublingual, vaginal, rectal) in reducing intraoperative blood loss, which remains a concern for the surgical management of uterine leiomyomas.

The protocol was registered in PROSPERO (CRD42025637576). Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) guidelines, we searched several databases (Ovid Medline, Embase, Scopus, Web of Science, Cochrane, Global Health, Global Index Medicus, ClinicalTrials.gov) through June 2024.

The references were screened and data were abstracted in Covidence for studies meeting inclusion criteria. Title abstract screening was conducted, followed by full-text review and then data abstraction. Analyses were conducted with R.

There were 328 studies identified in the initial search. Of those, 26 studies were included for analysis, but only 20 were able to undergo network meta-analysis against the primary outcome of interest (blood loss). Rectal misoprostol administration was associated with the largest mean reduction in intraoperative blood loss (mean difference −152.43 mL, 95% CI, −228.43 to −76.44, P<.0001), followed by vaginal administration (mean difference −69.46 mL, 95% CI, −122.11 to −16.82, P=.010). Sublingual administration was not statistically significant (mean difference −92.13 mL, 95% CI, −234.95 to 50.70, P=.206). Across other key outcomes (eg, blood transfusion, operative time), rectal misoprostol generally outperformed vaginal and sublingual modes of administration in our network meta-analysis.

Route of misoprostol administration does matter in reducing blood loss during abdominal myomectomy with rectal administration favored, although the data are limited for sublingual administration.

PROSPERO, CRD42025637576.