Remimazolam Versus Propofol for Sedation or Anaesthesia in Gynaecological Procedures: A Meta-Analysis of Randomised Controlled Trials

Background: The objective of this study was to compare remimazolam with propofol for intraoperative hypotension, hypoxaemia and other adverse events in short gynaecological procedures, analysing remimazolam alone and remimazolam–propofol co-administration separately. Materials and Methods: Randomised trials in women undergoing hysteroscopy, surgical abortion, conization or outpatient gynaecological surgery were identified from four earlier meta-analyses, targeted searches of PubMed, PubMed Central and trial registries, and the authors' collection; one reviewer screened and extracted the data. Risk ratios (RR) and risk differences were pooled with a random-effects model (REML, Hartung–Knapp adjustment). Risk of bias was assessed with RoB 2 and certainty of evidence with GRADE. Results: Thirteen monotherapy trials (1,764 women) were included. Hypotension (9 trials; RR 0.35, 95% CI 0.20–0.61), hypoxaemia below 90% (8 trials; RR 0.36, 0.23–0.55) and injection pain (12 trials; RR 0.09, 0.05–0.19) were less frequent with remimazolam. Hiccups were more frequent (4 trials; risk difference 12 percentage points, −1 to 25). There was no clear evidence of a difference in sedation failure (risk difference 1.2 points, −1.1 to 3.5) or body movement (RR 1.18, 0.50–2.77). Time to awakening was too heterogeneous to summarise (I² 100%). Results were similar when trials under general anaesthesia or with esketamine were excluded. In three co-administration trials, hypotension was also less frequent than with propofol alone (RR 0.35, 0.13–0.97). Conclusion: Remimazolam may reduce hypotension and hypoxaemia (low certainty) and probably substantially reduces injection pain (moderate certainty); hiccups may be more frequent (very low certainty). All trials were single-centre and from one country, and the search was not exhaustive.