Prophylactic Tranexamic Acid During Minimally Invasive Myomectomies

Study Overview
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Brief Summary
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This is a Double-blinded randomized placebo-controlled trial based at Eastern Virginia Medical School. Subjects who are identified in clinic having menorrhagia or abnormal Uterine bleeding (AUB) due to uterine fibroids and meet inclusion criteria based on the ultrasound (US) or Magnetic Resonance Imaging (MRI), aged 18-45 undergoing laparoscopic or Robotic assisted myomectomies. A total of 50 women in each arm of the study with symptomatic fibroids. Patients will be randomized to receive a single IV bolus injection of TXA 30mg/kg in 50ml of normal saline (intervention group) versus an IV bolus injection of normal saline of equivalent volume (placebo group) 15 minutes prior to initial surgical incision.

Detailed Description
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This is a Double-blinded randomized placebo-controlled trial based at Eastern Virginia Medical School. Subjects who are identified in clinic having menorrhagia or abnormal Uterine bleeding (AUB) due to uterine fibroids and meet inclusion criteria based on the ultrasound (US) or Magnetic Resonance Imaging (MRI), aged 18-45 undergoing laparoscopic or Robotic assisted myomectomies. These subjects will be then approached for consent during their pre-op visit 1-2 weeks prior to their surgery. The setting for consent will be in a patient consultation room. A total of 50 women in each arm of the study with symptomatic fibroids meeting any of the following criteria will be included in the study: At least one fibroid greater than or equal to 6 cm Any intramural or broad ligament fibroid greater than or equal to 4 cm At least 3 total fibroids based on preoperative imaging. Randomization will be performed using an automated randomization website Patients will be randomized to receive a single IV bolus injection of TXA 30mg/kg in 50ml of normal saline (intervention group) versus an IV bolus injection of normal saline of equivalent volume (placebo group) 15 minutes prior to initial surgical incision. This dosage will not be adjusted for patients with renal insufficiency as they will be excluded from the study. Preparation of the medications will be performed by anesthesia who have both medication and normal saline available to them on short notice. No prior preparation by pharmacy will be required. Tranexamic acid is readily available in a 10 ml vial, which does not need a pharmacist to prepare for administration. The vial is mixed with 50 ml of saline in the operating room. This is the same process that occurs outside of any study with any medication that is administered intra-operatively. This will in no way impact the patient's safety during the surgery, especially since it is administered 15 minutes prior to the start of the procedure. Both surgeon and patient will be blinded to the treatment arm. This dosage has been used previously in both obstetric and gynecological procedures and is the same dose recommended by the WHO for preventing post-partum hemorrhage The surgery itself will be scheduled at either Sentara Norfolk General, Sentara Leigh hospital, and Sentara Princess Anne hospital. These are the three sites that the investigators already perform Minimally invasive myomectomies. An envelope will be given to the anesthesiologist prior to the procedure informing whether they are to receives TXA or the placebo. Blood loss will be estimated by the surgeon performing the procedure. Hemoglobin and hematocrit will be obtained 24 hours post procedure. The patient will be assessed for reported side effects from the medication given will be assessed by a questionnaire that will be given at their post-op appointment at the 2 week and 6-week mark. During these two visits a physical exam is performed, checking incision sites, and patient symptoms, all of which are standard of care for any minimally invasive procedure. The patients will be seen at the EVMS outpatient clinic for Gynecology, or depending with the physician who performed the surgery. Data will be collected from both Allscripts and EPIC charts.

Official Title
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Randomized Control Trial Investigating for Prophylactic Tranexamic Acid Use at Time of Minimally Invasive Myomectomies

Conditions
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Fibroid Uterus, Abnormal Uterine Bleeding, Myoma;Uterus

Intervention / Treatment
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* Drug: Tranexamic Acid
* Drug: Placebos


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Undergoing laparoscopic myomectomy At least one fibroid greater than or equal to 6 cm Any intramural or broad ligament fibroid greater than or equal to 4 cm At least 3 total fibroids based on preoperative imaging Exclusion Criteria: Severe existing medical complications involving the heart, liver, or kidney Moderate to severe renal impairment (serum creatinine > 1.4) Blood clotting abnormalities Known Allergies to tranexamic acid Known Contraindications to Minimally invasive myomectomies If you are pregnant History of a prior blood clot in the lung arm or leg, known as pulmonary embolism or deep vein thrombosis Any active blood clots, clotting disease, pulmonary embolism, cerebral thrombosis, estrogen use, renal impairment, elevated creatinine level History of a stroke or mini-strokes Concurrent oral contraceptive use Contraindications to receiving Tranexamic acid In patients with acquired defective color vision, since this prohibits measuring one endpoint that should be followed as a measure of toxicity In patients with subarachnoid hemorrhage. Anecdotal experience indicates that cerebral edema and cerebral infarction may be caused by tranexamic acid in such patients. In patients with active intravascular clotting. In patients with hypersensitivity to tranexamic acid or any of the ingredients

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 45 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Randomized Double Blind Placebo clinical trial
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Tranexamic Acid<br>Patients will receive a single IV bolus injection of TXA 30mg/kg in 50ml of normal saline 15 minutes prior to initial surgical incision time | Drug: Tranexamic Acid<br>* IV Tranexamic acid in 50 ml will be given 15 minutes prior to initial surgical incision in the placebo group.<br>|
| Placebo Comparator: Placebo<br>Patients will receive an IV bolus injection of normal saline of equivalent volume (placebo group) 15 minutes prior to initial surgical incision | Drug: Placebos<br>* IV normal saline 50 ml will be given 15 minutes prior to initial surgical incision in the placebo group.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Estimated blood loss | Estimated blood loss at time of procedure completion; using volume of cannister and weight of lap sponges | Duration of procedure up to 420 minutes | 
| Calculated blood loss | Calculated Blood loss, using pre-operative hematocrit, postoperative hematocrit and estimated blood volume x Body Mass Index | From post operative day 0 until postoperative day 1 | 
| Number of blood products received | Number of blood products received during admission that is directly due to blood loss at time of procedure | Duration of hospital stay up to two days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Duration of surgery | Start time of procedure until end time of procedure | Duration of surgery up to 420 minutes | 
| Length of hospital stay | Recorded in days | Duration of stay in hospital, up to two days | 
| Number of fibroids removed | Total number of fibroids removed during procedure | Duration of surgery, up to 420 minutes | 
| Fibroid type | type of fibroid per FIGO classification | through completion of study average 8 weeks | 
| Weight of fibroids removed | total weight of fibroids removed | duration of surgery up to 420 minutes | 
| Pain index | Pain index score on postoperative day 1 and 14 Score of 0-10 0 = no pain, 10 = significant amount of pain | duration of hospital stay, up to two days | 
| Incidence of postoperative complication | Immediate postoperative complication: Hemorrhage Infection Fever Deep vein thrombosis Hysterectomy Re-exploration Hospital readmission | Duration of hospital stay , up to two days | 
| Questionnaire for incidence of mild side effect of medication | Reported mild effective of medication of post operative day 1 | only on postoperative day 1 , one day | 
| Questionnaire for incidence of serious side effect of medication | Reported serious side effect of medication on post operative day 1 | Only on postoperative day 1, one day | 
| tPA receptor | Percentage of tPA receptor located in fibroid and myometrium | From time of randomization until postoperative visit, four weeks | 
| PAI-1 receptor | Percentage of PAI-1receptor located in fibroid and myometrium | From time of randomization until postoeprative visit, four weeks | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Tranexamic acid, Minimally Invasive, Myomectomy, Fibroid