Efficacy of a kaolin-impregnated gauze in the prevention of postoperative bleeding after cervical conization

Objective: To evaluate the efficacy of a kaolin-impregnated gauze in preventing postoperative bleeding after a loop electrosurgical excision procedure (LEEP). Methods: The medical records of 1322 women who underwent a LEEP at a university hospital were retrospectively reviewed, of which 1006 patients who fulfilled the inclusion criteria were included in the final analysis. During the study period, the bleeding in patients undergoing a LEEP was managed with the application of a kaolin-impregnated gauze (treatment group, n = 539) or without application of a kaolin-impregnated gauze (control group, n = 467). The primary outcome measure was the incidence of postoperative bleeding requiring hemostatic intervention after a LEEP. A logistic regression model was used to identify the clinical variables for postoperative bleeding. Results: The baseline characteristics were similar between the two study groups. Postoperative vaginal bleeding necessitating an intervention was observed in 12.8% of the study population (129 of 1006 women), with a significant difference between the two groups (9.3% in the treatment group vs. 16.9% in the control group; p $<$ 0.001). On multivariate analysis, significantly lower postoperative bleeding was observed with the use of a kaolin-impregnated gauze than without its use (odds ratio = 0.496; 95% confidence interval = 0.267–0.870; p = 0.009). Conclusions: Prophylactic use of a kaolin-impregnated gauze reduced the incidence of postoperative bleeding after a LEEP.

Bleeding; Cervical intraepithelial neoplasia; Conization; LEEP; Hemorrhage; Kaolin-impregnated gauze

[1] Martin-Hirsch PP, Paraskevaidis E, Bryant A, Dickinson HO. Surgery for cervical intraepithelial neoplasia. Cochrane Database of Systematic Reviews. 2013; CD001318.

[2] Mitchell MF, Tortolero-Luna G, Cook E, Whittaker L, Rhodes-Morris H, Silva E. A randomized clinical trial of cryotherapy, laser vaporization, and loop electrosurgical excision for treatment of squamous intraepithelial lesions of the cervix. Obstetrics and Gy- necology. 1998; 92: 737–744.

[3] Bueno LR, Binda M, Monego H, Scherer RL, Rolim KM, Bottini AL, et al. Randomized clinical trial comparing cold knife coniza- tion of the cervix with and without lateral hemostatic sutures. International Journal of Surgery. 2015; 18: 224–229.

[4] Jiang YM, Chen CX, Li L. Meta-analysis of cold-knife conization versus loop electrosurgical excision procedure for cervical intraep- ithelial neoplasia. OncoTargets and Therapy. 2016; 9: 3907–3915.

[5] Wright TC Jr, Gagnon S, Richart RM, Ferenczy A. Treatment of cervical intraepithelial neoplasia using the loop electrosurgical excision procedure. Obstetrics and Gynecology. 1992; 79: 173–178.

[6] Lee YJ, Park Y, Lee IO, Yoon JW, Lee JY, Kim SW, et al. Delayed hemorrhage effect of local anesthesia with epinephrine in the loop electrosurgical excisional procedure. Obstetrics & Gynecology Sci- ence. 2017; 60: 87–91.

[7] Rybo G, Westerberg H. The effect of tranexamic acid (AMCA) on postoperative bleeding after conization. Acta Obstetricia et Gynecologica Scandinavica. 1972; 51: 347–350.

[8] Lee ET, Ozumba EN, Bevan JR. A randomized trial of Citanest with Octapressin for relief of pain associated with laser vaporiza- tion of the cervix. British Journal of Obstetrics and Gynaecology. 1986; 93: 967–969.

[9] Doyle M, Warwick A, Redman C, Hillier C, Chenoy R, O’Brien S. Does application of Monsel’s solution after loop diathermy exci- sion of the transformation zone reduce post operative discharge? Results of a prospective randomised controlled trial. British Jour- nal of Obstetrics and Gynaecology. 1992; 99: 1023–1024.

[10] Kim JH, Park TC, Park GA, Song JY, Kim YH, Lee HJ, et al. A pilot study to investigate the efficacy of fibrin sealant (tisseel(R)) in the loop electrosurgical excision procedure. Gynecologic and Obstetric Investigation. 2015; 80: 21–25.

[11] Kim JJ, Kim WY, Lee DH, Kang JH, Song T, Lee KW, et al. Ef- ficacy of TachoSil® in preventing hemorrhage after loop electrosurgical excision procedure. European Journal of Obstetrics & Gy- necology and Reproductive Biology. 2015; 194: 245–248.

[12] Kheirabadi BS, Scherer MR, Estep JS, Dubick MA, Holcomb JB. Determination of efficacy of new hemostatic dressings in a model of extremity arterial hemorrhage in Swine. Journal of Trauma: In- jury, Infection & Critical Care. 2009; 67: 450–459.

[13] Patel SA, Martin M, Chamales I. Vaginal hemorrhage from tran- sobturator sling controlled with QuikClot combat gauze. Military Medicine. 2012; 177: 997–998.

[14] Vilardo N, Feinberg J, Black J, Ratner E. The use of QuikClot com- bat gauze in cervical and vaginal hemorrhage. Gynecologic Oncol- ogy Reports. 2017; 21: 114–116.

[15] Motamedi MHK, Sagafinia M. QuickClot combat gauze use for hemorrhage control in military trauma. Prehospital and Disaster Medicine. 2012; 26: 237.

[16] Gegel BT, Austin PN, Johnson AD. An evidence-based review of the use of a combat gauze (QuikClot) for hemorrhage control. AANA Journal. 2013; 81: 453–458.

[17] Kim K, Park S, Kim B, Kim M, Choi S, Ryu S, et al. Efficacy of fibrin sealant in reducing hemorrhage after a loop electrosurgi- cal excision procedure. Gynecologic and Obstetric Investigation. 2012; 74: 1–5.