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Wang V, Dhoon TQ, Steller J, Carusillo D, Rahimian R, Vakharia S, Rinehart J. An Unusual Presentation of an Amniotic Fluid Embolism: Fetal Bradycardia As the First Sign. Cureus 2024; 16:e67222. [PMID: 39295719 PMCID: PMC11410296 DOI: 10.7759/cureus.67222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2024] [Indexed: 09/21/2024] Open
Abstract
Amniotic fluid embolism (AFE) is a potentially fatal maternal condition demanding awareness from obstetricians and anesthesiologists regarding its different manifestations. The typical presentation involves maternal respiratory distress, cardiovascular collapse, neurological changes, and coagulopathy followed by fetal distress. This unusual case study emphasizes that fetal compromise may precede maternal decompensation as the initial sign of AFE. Fetal distress is a known symptom of AFE and is typically seen due to cardiorespiratory issues that lead to reduced uteroplacental perfusion, resulting in fetal hypoxia. In the case presented, fetal bradycardia occurred before any visible maternal symptoms, suggesting that fetal distress could be induced by factors independent of the mother's cardiopulmonary status. A 34-year-old healthy G4P2012 at 41 weeks and 2 days gestation who was initially laboring on the floor was emergently taken to the operating room for a cesarean delivery due to fetal bradycardia. Around the time the fetus was delivered, the patient displayed seizure activity, followed by a complete loss of consciousness and cardiac arrest. The patient was intubated and underwent cardiopulmonary resuscitation and defibrillation, subsequently converting to a wide complex tachycardia. In the operating room, there was evidence of heavy vaginal bleeding, uterine atony, and a fulminant form of disseminated intravascular coagulopathy (DIC), which required aggressive management over the next four hours. After achieving hemodynamic stability, the patient was transferred to the surgical intensive care unit (SICU), extubated on day 3, and discharged home on day 8.
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Affiliation(s)
- Vicki Wang
- Anesthesiology and Perioperative Medicine, UCI Health, Orange, USA
| | | | - John Steller
- Obstetrics and Gynecology, UCI Health, Orange, USA
| | | | - Ramin Rahimian
- Anesthesiology and Perioperative Medicine, UCI Health, Orange, USA
| | | | - Joseph Rinehart
- Anesthesiology and Perioperative Care, UCI Health, Orange, USA
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Samara A, Hanton T, Khalil A. Evidence-based interventions to address persistent maternal mortality rates. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024. [PMID: 39005146 DOI: 10.1002/uog.27712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 05/25/2024] [Accepted: 06/07/2024] [Indexed: 07/16/2024]
Affiliation(s)
- A Samara
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- FUTURE, Center for Functional Tissue Reconstruction, University of Oslo, Oslo, Norway
| | - T Hanton
- York and Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Royal College of Obstetricians and Gynaecologists, London, UK
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Pingray V, Williams CR, Al-Beity FMA, Abalos E, Arulkumaran S, Blumenfeld A, Carvalho B, Deneux-Tharaux C, Downe S, Dumont A, Escobar MF, Evans C, Fawcus S, Galadanci HS, Hoang DTT, Hofmeyr GJ, Homer C, Lewis AG, Liabsuetrakul T, Lumbiganon P, Main EK, Maua J, Muriithi FG, Nabhan AF, Nunes I, Ortega V, Phan TNQ, Qureshi ZP, Sosa C, Varallo J, Weeks AD, Widmer M, Oladapo OT, Gallos I, Coomarasamy A, Miller S, Althabe F. Strategies for optimising early detection and obstetric first response management of postpartum haemorrhage at caesarean birth: a modified Delphi-based international expert consensus. BMJ Open 2024; 14:e079713. [PMID: 38719306 PMCID: PMC11086283 DOI: 10.1136/bmjopen-2023-079713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 02/19/2024] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVE There are no globally agreed on strategies on early detection and first response management of postpartum haemorrhage (PPH) during and after caesarean birth. Our study aimed to develop an international expert's consensus on evidence-based approaches for early detection and obstetric first response management of PPH intraoperatively and postoperatively in caesarean birth. DESIGN Systematic review and three-stage modified Delphi expert consensus. SETTING International. POPULATION Panel of 22 global experts in PPH with diverse backgrounds, and gender, professional and geographic balance. OUTCOME MEASURES Agreement or disagreement on strategies for early detection and first response management of PPH at caesarean birth. RESULTS Experts agreed that the same PPH definition should apply to both vaginal and caesarean birth. For the intraoperative phase, the experts agreed that early detection should be accomplished via quantitative blood loss measurement, complemented by monitoring the woman's haemodynamic status; and that first response should be triggered once the woman loses at least 500 mL of blood with continued bleeding or when she exhibits clinical signs of haemodynamic instability, whichever occurs first. For the first response, experts agreed on immediate administration of uterotonics and tranexamic acid, examination to determine aetiology and rapid initiation of cause-specific responses. In the postoperative phase, the experts agreed that caesarean birth-related PPH should be detected primarily via frequently monitoring the woman's haemodynamic status and clinical signs and symptoms of internal bleeding, supplemented by cumulative blood loss assessment performed quantitatively or by visual estimation. Postoperative first response was determined to require an individualised approach. CONCLUSION These agreed on proposed approaches could help improve the detection of PPH in the intraoperative and postoperative phases of caesarean birth and the first response management of intraoperative PPH. Determining how best to implement these strategies is a critical next step.
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Affiliation(s)
- Verónica Pingray
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Caitlin R Williams
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
- Department of Maternal & Child Health, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Fadhlun M Alwy Al-Beity
- Department of Obstetrics & Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Edgardo Abalos
- Maternidad Martin, Secretaría de Salud Pública de la Municipalidad de Rosario, Rosario, Santa Fe, Argentina
- Centro de Estudios de Estado y Sociedad, Buenos Aires, Argentina
| | | | - Alejandro Blumenfeld
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
- Department of Public Health, Faculty of Medicine, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Brendan Carvalho
- Stanford University School of Medicine, Stanford, California, USA
| | - Catherine Deneux-Tharaux
- Obstetrical Perinatal and Pediatric Epidemiology Research team, Centre for Research in Statistics and Epidemiology (CRESS) Université Paris Cité INSERM, Paris, France
| | - Soo Downe
- Research in Childbirth and Health, University of Central Lancashire, Preston, UK
- THRIVE Centre, School of Heath and Community Studies, University of Central Lancashire, Preston, UK
| | | | - Maria Fernanda Escobar
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
| | - Cherrie Evans
- Technical Leadership & Innovations Office, Jhpiego/USA, Baltimore, Maryland, USA
| | - Sue Fawcus
- Department of Obstetrics and Gynaecology, University of Cape Town, Rondebosch, South Africa
| | - Hadiza S Galadanci
- Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Kano, Nigeria
- Africa Center of Excellence for Population Health and Policy, Bayero University Kano, Kano, Nigeria
| | | | - G Justus Hofmeyr
- Department of Obstetrics and Gynaecology, University of Botswana, Gaborone, Botswana
- Effective Care Research Unit, University of the Witwatersrand, Johannesburg and Walter Sisulu University, Mthatha, South Africa
| | | | | | - Tippawan Liabsuetrakul
- Department of Epidemiology, Prince of Songkla University, Hat Yai, Thailand
- Department of Obstetrics & Gynecology, Prince of Songkla University, Hat Yai, Thailand
| | - Pisake Lumbiganon
- Department of Obstetrics and Gynaecology, Khon Kaen University, Khon Kaen, Thailand
| | - Elliott K Main
- Department of Obstetrics & Gynecology-Maternal Fetal Medicine, Stanford University, Stanford, California, USA
- California Maternal Quality Care Collaborative, Standford, California, USA
| | - Judith Maua
- Liverpool School of Tropical Medicine, Nairobi, Kenya
| | - Francis G Muriithi
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Obstetrics and Gynaecology, Singleton Hospital, Swansea Bay University Health Board, Swansea, UK
| | - Ashraf Fawzy Nabhan
- Department of Obstetrics & Gynecology, Ain Shams University Faculty of Medicine, Cairo, Egypt
| | - Inês Nunes
- Department of Obstetrics and Gynaecology, Gaia/ Espinho Local Health Unit, Vila Nova de Gaia, Portugal
- RISE-HEALTH - CINTESIS-Center for Health Technology and Services Research, University of Porto, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Vanesa Ortega
- Department of Mother and Child Health Research, Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Thuan N Q Phan
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
- Department of Delivery, Tu Du Hospital, Ho Chi Minh City, Viet Nam
| | - Zahida P Qureshi
- University of Nairobi Department of Obstetrics and Gynecology, Nairobi, Kenya
| | - Claudio Sosa
- Woman and Reproduction Health Unit at Maternal Health at the Latin American Center of Perinatology (CLAP/WR), Pan American Health Organization, Montevideo, District of Columbia, USA
- Department of Obstetrics and Gynecology, School of Medicine, Universidad de la República Uruguay, Montevideo, Uruguay
| | - John Varallo
- Women's Health, Global Surgery Foundation, Washington, District of Columbia, USA
| | - Andrew D Weeks
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
- Liverpool Women's Hospital, Liverpool, UK
| | - Mariana Widmer
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Olufemi T Oladapo
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Ioannis Gallos
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Arri Coomarasamy
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Suellen Miller
- Bixby Center for Global reproductive Health, University of California San Francisco, San Francisco, California, USA
| | - Fernando Althabe
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
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Alsumadi M, Basha A, AlSumadi A, Obeidat Z, AbuKhalaf B, Sulieman A, Shuwehdi S, AlDeffaie A, AlQaqaa A, Zakaryia A. Tranexamic Acid Use in Obstetric Hemorrhage: Knowledge and Attitude Among Jordanian Obstetricians and Gynecologists. Cureus 2024; 16:e57360. [PMID: 38694422 PMCID: PMC11061548 DOI: 10.7759/cureus.57360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2024] [Indexed: 05/04/2024] Open
Abstract
AIM Tranexamic acid (TXA) use in obstetric hemorrhage has been shown to decrease both maternal mortality and morbidity. This study aimed to explore the knowledge and attitudes of Jordanian obstetricians and gynecologists regarding the use of TXA in obstetric bleeding cases, as well as to identify factors that affect decision-making processes and emphasize the significance of TXA in enhancing maternal health outcomes. METHODOLOGY This study used a cross-sectional design and a structured questionnaire to gather data from a convenience sample of 1000 Jordanian obstetricians. RESULTS Most participants used TXA to address obstetric hemorrhage, with medical training being the primary source of knowledge about TXA for (113/166) 68.1% of respondents. Awareness of TXA's potential benefits was high but some misconceptions existed. Approximately (96/166) 57.8% of the participants were aware of the recommended dosage regimen, and (61/166) 36.7% emphasized the importance of timing of administration. Knowledge of potential side effects was notable, with (55/166) 33.1% aware of life-threatening side effects, such as pulmonary embolism and deep vein thrombosis. Concerns regarding barriers to implementation included the absence of strict guidelines (54.8%) and drug availability ( 91/166; 54.8%). However, (64/166) 38.6% expressed confidence in the effective use of TXA for obstetric hemorrhage treatment. The majority of respondents (154/166; 92.8%) considered additional education and training on TXA use to be important in managing obstetric hemorrhage. CONCLUSION Jordanian obstetricians have used TXA in cases of obstetric hemorrhage despite their experience and knowledge based only on limited resources; the need for national guidelines on when and how to use TXA in obstetric practice is of great importance and got vast support from the Jordanian obstetricians.
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Affiliation(s)
- Maen Alsumadi
- Obstetrics and Gynaecology, Epsom and St Helier University Hospitals, London, GBR
| | - Asma Basha
- Obstetrics and Gynaecology, The University of Jordan, Amman, JOR
| | - Amro AlSumadi
- Trauma and Orthopaedics, School of Medicine, University of Jordan, Amman, JOR
- Obstetrics and Gynaecology, School of Medicine, University of Jordan, Amman, JOR
| | - Zeina Obeidat
- Obstetrics and Gynaecology, Epsom and St Helier University Hospitals, London, GBR
| | | | | | - Sleman Shuwehdi
- Obstetrics and Gynaecology, University of Jordan, Amman, JOR
| | | | - Ahmed AlQaqaa
- Obstetrics and Gynaecology, University of Jordan, Amman, JOR
| | - Aiman Zakaryia
- Obstetrics and Gynaecology, University of Jordan, Amman, JOR
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VanderMeulen H, Tang GH, Sholzberg M. Tranexamic acid for management of heavy vaginal bleeding: barriers to access and myths surrounding its use. Res Pract Thromb Haemost 2024; 8:102389. [PMID: 38623473 PMCID: PMC11017359 DOI: 10.1016/j.rpth.2024.102389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/09/2024] [Accepted: 03/11/2024] [Indexed: 04/17/2024] Open
Abstract
Tranexamic acid is safe and effective for the treatment of heavy vaginal bleeding during menstruation and childbirth. It improves the quality of life, facilitates participation in school and work, and reduces the risk of death from postpartum hemorrhage. Despite its well-established benefits, individual- and structural-level barriers preclude its widespread utilization, hindering effective patient care and perpetuating health inequities in women's health. We first describe the evidence for the use of tranexamic acid in treating heavy menstrual bleeding and postpartum hemorrhage. Barriers to tranexamic acid use, including structural sexism, period poverty, misinformation in product monograph labeling, stigmatization of vaginal blood loss, and drug access, are then discussed. Finally, we summarize relevant data presented during the 2023 International Society on Thrombosis and Haemostasis Congress.
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Affiliation(s)
- Heather VanderMeulen
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Grace H. Tang
- Department of Hematology, Hematology-Oncology Clinical Research Group, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Michelle Sholzberg
- Department of Medicine and Laboratory Medicine & Pathobiology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
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Franchini M, Focosi D, Zaffanello M, Mannucci PM. Efficacy and safety of tranexamic acid in acute haemorrhage. BMJ 2024; 384:e075720. [PMID: 38176733 DOI: 10.1136/bmj-2023-075720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Italy
| | - Marco Zaffanello
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico and University of Milan, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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Kalsvik S, Lukasse M, Myhre EL. Midwives' experiences with aortic compression for postpartum hemorrhage: A qualitative study. Eur J Midwifery 2023; 7:35. [PMID: 38023946 PMCID: PMC10665914 DOI: 10.18332/ejm/172880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 09/22/2023] [Accepted: 10/20/2023] [Indexed: 12/01/2023] Open
Abstract
INTRODUCTION The aim of this study was to examine midwives' firsthand experience with aortic compression during postpartum hemorrhage. Severe postpartum hemorrhage is a critical complication during childbirth and the leading cause of maternal morbidity and mortality. Active management of the third stage of labor, combined with standard treatment, has reduced the incidence. However, these measures occasionally fall short, and there is a global need for easy, effective alternative methods. Aortic compression, though not widely recognized, is employed intermittently and lacks substantial scientific backing. METHODS This qualitative study comprised interviews with midwives from various healthcare settings across Norway. Over a two-month period in 2022, we conducted seven individual semi-structured interviews. Interview transcripts were thematically analyzed using Braun and Clarke's six-step process. RESULTS Four prominent themes emerged from the analysis, reflecting midwives' experiences with aortic compression in managing postpartum hemorrhage (PPH). In their experiences with aortic compression, midwives uncovered its dual qualities of being both easy and effective. Their utilization of the technique was experience-based only, shaped by personal experience rather than formal training. Nevertheless, aortic compression was perceived as the first-line response to suspected postpartum hemorrhage, preventing escalation, and offering a clearer view of the situation to facilitate timely treatment. Most significantly, midwives recognized aortic compression as a crucial intervention that reduces blood loss and improves health. CONCLUSIONS Postpartum hemorrhage is a feared situation in the delivery room. The participants consider that aortic compression may affect maternal health and mortality. However, further research is necessary.
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Affiliation(s)
- Sonja Kalsvik
- Centre for Women’s, Family and Child Health, Faculty of Health Sciences, University of South-Eastern Norway, Kongsberg, Norway
| | - Mirjam Lukasse
- Centre for Women’s, Family and Child Health, Faculty of Health Sciences, University of South-Eastern Norway, Kongsberg, Norway
| | - Enid L. Myhre
- Centre for Women’s, Family and Child Health, Faculty of Health Sciences, University of South-Eastern Norway, Kongsberg, Norway
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Cleveland B, Norling B, Wang H, Gandhi V, Price CL, Borofsky MS, Pais V, Dahm P. Tranexamic acid for percutaneous nephrolithotomy. Cochrane Database Syst Rev 2023; 10:CD015122. [PMID: 37882229 PMCID: PMC10600962 DOI: 10.1002/14651858.cd015122.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
BACKGROUND Percutaneous nephrolithotomy (PCNL) is the gold standard for the treatment of large kidney stones but comes with an increased risk of bleeding compared to other treatments, such as ureteroscopy and shock wave lithotripsy. Tranexamic acid (TXA) is an antifibrinolytic agent that has been used to reduce bleeding complications in other settings. OBJECTIVES To assess the effects of TXA in individuals with kidney stones undergoing PCNL. SEARCH METHODS We performed a comprehensive literature search of the Cochrane Library, PubMed (including MEDLINE), Embase, Scopus, Global Index Medicus, trials registries, other sources of the grey literature, and conference proceedings. We applied no restrictions on the language of publication nor publication status. The latest search date was 11 May 2023. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared treatment with PCNL with administration of TXA to placebo (or no TXA) for patients ≥ 18 years old. DATA COLLECTION AND ANALYSIS Two review authors independently classified studies and abstracted data. Primary outcomes were: blood transfusion, stone-free rate (SFR), and thromboembolic events (TEEs). Secondary outcomes were: adverse events (AEs), secondary interventions, major surgical complications, minor surgical complications, unplanned hospitalizations or readmissions, and hospital length of stay (LOS). We performed statistical analyzes using a random-effects model. We rated the certainty of evidence (CoE) according to the GRADE approach using a minimally contextualized approach with predefined thresholds for minimally clinically important differences (MCIDs). MAIN RESULTS We analyzed 10 RCTs assessing the effect of systemic TXA in PCNL versus placebo (or no TXA) with 1883 randomized participants. Eight studies were published as full text. One was published in abstract proceedings, but it was separated into two separate studies for the purpose of our analyzes. Average stone surface area ranged 3.45 to 6.62 cm2. We also found a single RCT published in full text assessing the effects of topical TXA in PCNL versus placebo (or no TXA) with 400 randomized participants, the results of which are further described in the review. Here we focus only on the results of TXA used systemically. Blood transfusion - Based on a representative baseline risk of 5.7% for blood transfusions taken from a large presentative observational studies, systemic TXA may reduce blood transfusions (risk ratio (RR) 0.45, 95% confidence interval (CI) 0.27 to 0.76; I2 = 28%; 9 studies, 1353 participants; low CoE). We assumed an MCID of ≥ 2%. Based on 57 participants per 1000 with placebo (or no TXA) being transfused, this corresponds to 31 fewer (from 42 fewer to 14 fewer) participants being transfused per 1000. Stone-free rate - Based on a representative baseline risk of 75.7% for SFR, systemic TXA may increase SFRs (RR 1.11, 95% CI 0.98 to 1.27; I2 = 62%; 4 studies, 603 participants; low CoE). We assumed an MCID of ≥ 5%. Based on 757 participants per 1000 being stone free with placebo (or no TXA), this corresponds to 83 more (from 15 fewer to 204 more) stone-free participants per 1000. Thromboembolic events - There is probably no difference in TEEs (risk difference (RD) 0.00, 95% CI -0.01 to 0.01; I2 = 0%; 6 studies, 841 participants; moderate CoE). We assumed an MCID of ≥ 2%. Since there were no thromboembolic events in intervention and/or control groups in 5 out of6 studies, we opted to assess a risk difference with systemic TXA for this outcome. Adverse events - Systemic TXA may increase AEs (RR 5.22, 95% CI 0.52 to 52.72; I2 = 75%; 4 studies, 602 participants; low CoE). We assumed an MCID of ≥ 5%. Based on 23 participants per 1000 with placebo (or no TXA) having an adverse event, this corresponds to 98 more (from 11 fewer to 1000 more) participants with adverse events per 1000. Secondary interventions - Systemic TXA may have little to no effect on secondary interventions (RR 1.15, 95% CI 0.84 to 1.57; I2 = 0%; 2 studies, 319 participants; low CoE). We assumed an MCID of ≥ 5%. Based on 278 participants per 1000 with placebo (or no TXA) having a secondary intervention, this corresponds to 42 more (from 44 fewer to 158 more) participants with secondary interventions per 1000. Major surgical complications - Based on a representative baseline risk for major surgical complications of 4.1%, systemic TXA may reduce major surgical complications (RR 0.36, 95% CI 0.21 to 0.62; I2 = 0%; 5 studies, 733 participants; moderate CoE). We assumed an MCID of ≥ 2%. Based on 41 participants per 1000 with placebo (or no TXA) having a major surgical complication, this corresponds to 26 fewer (from 32 fewer to 16 fewer) participants with major surgical complications per 1000. Minor surgical complications - Systemic TXA may reduce minor surgical complications (RR 0.71, 95% CI 0.45 to 1.10; I2 = 76%; 5 studies, 733 participants; low CoE). We assumed an MCID of ≥ 5%. Based on 396 participants per 1000 with placebo (or no TXA) having a minor surgical complication, this corresponds to 115 fewer (from 218 fewer to 40 more) participants with minor surgical complications per 1000. Unplanned hospitalizations or readmissions - We are very uncertain how unplanned hospitalizations or readmissions are affected (RR 1.55, 95% CI 0.45 to 5.31; I2 = not applicable; 1 study, 189 participants; very low CoE). We assumed an MCID of ≥ 2%. Hospital length of stay - Systemic TXA may reduce hospital LOS (mean difference 0.52 days lower, 95% CI 0.93 lower to 0.11 lower; I2 = 98%; 7 studies, 1151 participants; low CoE). We assumed an MCID of ≥ 0.5 days. AUTHORS' CONCLUSIONS Based on 10 RCTs with substantial methodological limitations that lowered all CoE of effect, we found that systemic TXA in PCNL may reduce blood transfusions, major and minor surgical complications, and hospital LOS, as well as improve SFRs; however, it may increase AEs. We are uncertain about the effects of systemic TXA on other outcomes. Findings of this review should assist urologists and their patients in making informed decisions about the use of TXA in the setting of PCNL.
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Affiliation(s)
- Brent Cleveland
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - Brett Norling
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Hill Wang
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | | | - Carrie L Price
- Albert S. Cook Library, Towson University, Towson, Maryland, USA
| | - Michael S Borofsky
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Vernon Pais
- Department of Surgery, Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
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9
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Mocanu V, Wilson H, Verhoeff K, Kung J, Walsh C, Koloszvari N, Neville A, Karmali S. Role of Tranexamic Acid (TXA) in Preventing Bleeding Following Sleeve Gastrectomy: a Systematic Review and Meta-analysis. Obes Surg 2023; 33:1571-1579. [PMID: 36977890 DOI: 10.1007/s11695-023-06563-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/15/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) has drawn growing interest over the last decade for its benefit in optimizing post-operative bleeding, yet its role in bariatric surgery is poorly understood. METHODS The medical librarian developed and executed comprehensive searches on September 28, 2022. The population of interest included adults who underwent elective bariatric surgery. The intervention was tranexamic acid administration while the comparison was placebo or standard peri-operative therapy. The primary outcome of interest was post-operative bleeding which was defined a priori. RESULTS A total of four studies were identified comprising of 475 patients. Of those, 207 (50%) received TXA at induction and all underwent laparoscopic sleeve gastrectomy (LSG). The majority of patients were female (n = 343, 80.7%) with ages ranging from 17 to 70 years of age and mean BMIs ranging from 37 to 56 kg/m2. Post-operative bleeding after LSG ranged from 0 to 28% depending on bleed definition and TXA administration with no differences in venous thromboembolic events or mortality between groups. Meta-analysis of post-operative bleeding demonstrated a statistically significant benefit with TXA administration (OR 0.40; 95% CI 0.23-0.70; p = 0.001) for patients undergoing elective LSG. CONCLUSIONS Intravenous tranexamic acid at the time of laparoscopic sleeve gastrectomy is associated with a significant reduction of post-operative bleeding with no observed differences in thromboembolic events or mortality. Further high-quality studies are needed to better delineate the ideal bariatric population to receives TXA in addition to the optimal timing, dose, and duration of TXA therapy.
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Affiliation(s)
- Valentin Mocanu
- Department of Surgery, University of Alberta Hospital, University of Alberta, 8440 112 Street NW, Edmonton, AB, T6G 2B7, Canada.
| | - Hillary Wilson
- Department of Medicine, University of Alberta Hospital, University of Alberta, 8440 112 Street NW, Edmonton, AB, T6G 2B7, Canada
| | - Kevin Verhoeff
- Department of Surgery, University of Alberta Hospital, University of Alberta, 8440 112 Street NW, Edmonton, AB, T6G 2B7, Canada
| | - Janice Kung
- MLIS John W. Scott Health Sciences Library, University of Alberta, Mackenzie Health Sciences Centre, 2K3.28 Walter C, Edmonton, AB, Canada
| | - Caolan Walsh
- Center for Foregut, Bariatric, and Minimally Invasive Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Nicole Koloszvari
- Center for Foregut, Bariatric, and Minimally Invasive Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Amy Neville
- Center for Foregut, Bariatric, and Minimally Invasive Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Shahzeer Karmali
- Centre for Advancement of Surgical Education and Simulation (CASES), Royal Alexandra Hospital, Edmonton, AB, Canada
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10
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Litman EA, Ma P, Miran SA, Nelson SJ, Ahmadzia HK. Recent trends in tranexamic acid use during postpartum hemorrhage in the United States. J Thromb Thrombolysis 2023; 55:742-746. [PMID: 36826757 DOI: 10.1007/s11239-023-02785-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2023] [Indexed: 02/25/2023]
Abstract
INTRODUCTION Postpartum hemorrhage (PPH) was the second leading cause of maternal death, accounting for approximately 14% of all pregnancy-related deaths between 2017 and 2019 in the United States. Several large multi-center studies have demonstrated decreased PPH rates with the use of tranexamic acid (TXA). Little data exists regarding the prevalence of TXA use in obstetric patients. METHODS We identified over 1.2 million US pregnancies between January 1, 2015 and June 30, 2021, with and without PPH by International Statistical Classification of Disease and Related Health Problems, Tenth Revision codes using Cerner Real-World Database™. TXA use and patient characteristics were abstracted from the electronic medical record. RESULTS During delivery, TXA was used approximately 1% of the time (12,394 / 1,262,574). Pregnant patients who did and did not receive TXA during delivery had similar demographic characteristics. Pregnant patients who underwent cesarean delivery (4,356 / 12,394), had a term delivery (10,199 / 12,394), and had comorbid conditions were more likely to receive TXA during hospitalization for delivery. The majority of TXA was use was concentrated in Arizona, Colorado, Idaho, New Mexico, Nevada, Utah, and Wyoming. During the study period the use of TXA increased in both patients with PPH and those without. CONCLUSION The data illustrate a rapid increase in the use of TXA after 2017 while the total number of pregnancies remained relatively constant. The observed increase in TXA use may reflect changing practicing patterns as the support for use of TXA in the setting of PPH prophylaxis increases.
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Affiliation(s)
- Ethan A Litman
- Department of Obstetrics and Gynecology, George Washington University, 2150 Pennsylvania Ave NW, 20037, Washington, DC, USA.
| | - Phillip Ma
- Biomedical Informatics Center, George Washington University, Washington, DC, USA
| | - Seyedeh A Miran
- Biomedical Informatics Center, George Washington University, Washington, DC, USA
| | - Stuart J Nelson
- Biomedical Informatics Center, George Washington University, Washington, DC, USA
| | - Homa K Ahmadzia
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, George Washington University, Washington, DC, USA
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11
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Beverly A, Ong G, Kimber C, Sandercock J, Dorée C, Welton NJ, Wicks P, Estcourt LJ. Drugs to reduce bleeding and transfusion in major open vascular or endovascular surgery: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2023; 2:CD013649. [PMID: 36800489 PMCID: PMC9936832 DOI: 10.1002/14651858.cd013649.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
BACKGROUND Vascular surgery may be followed by internal bleeding due to inadequate surgical haemostasis, abnormal clotting, or surgical complications. Bleeding ranges from minor, with no transfusion requirement, to massive, requiring multiple blood product transfusions. There are a number of drugs, given systemically or applied locally, which may reduce the need for blood transfusion. OBJECTIVES To assess the effectiveness and safety of anti-fibrinolytic and haemostatic drugs and agents in reducing bleeding and the need for blood transfusion in people undergoing major vascular surgery or vascular procedures with a risk of moderate or severe (> 500 mL) blood loss. SEARCH METHODS We searched: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL, and Transfusion Evidence Library. We also searched the WHO ICTRP and ClinicalTrials.gov trial registries for ongoing and unpublished trials. Searches used a combination of MeSH and free text terms from database inception to 31 March 2022, without restriction on language or publication status. SELECTION CRITERIA We included randomised controlled trials (RCTs) in adults of drug treatments to reduce bleeding due to major vascular surgery or vascular procedures with a risk of moderate or severe blood loss, which used placebo, usual care or another drug regimen as control. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were units of red cells transfused and all-cause mortality. Our secondary outcomes included risk of receiving an allogeneic blood product, risk of reoperation or repeat procedure due to bleeding, risk of a thromboembolic event, risk of a serious adverse event and length of hospital stay. We used GRADE to assess certainty of evidence. MAIN RESULTS We included 22 RCTs with 3393 participants analysed, of which one RCT with 69 participants was reported only in abstract form, with no usable data. Seven RCTs evaluated systemic drug treatments (three aprotinin, two desmopressin, two tranexamic acid) and 15 RCTs evaluated topical drug treatments (drug-containing bioabsorbable dressings or glues), including fibrin, thrombin, collagen, gelatin, synthetic sealants and one investigational new agent. Most trials were conducted in high-income countries and the majority of the trials only included participants undergoing elective surgery. We also identified two ongoing RCTs. We were unable to perform the planned network meta-analysis due to the sparse reporting of outcomes relevant to this review. Systemic drug treatments We identified seven trials of three systemic drugs: aprotinin, desmopressin and tranexamic acid, all with placebo controls. The trials of aprotinin and desmopressin were small with very low-certainty evidence for all of our outcomes. Tranexamic acid versus placebo was the systemic drug comparison with the largest number of participants (2 trials; 1460 participants), both at low risk of bias. The largest of these included a total of 9535 individuals undergoing a number of different higher risk surgeries and reported limited information on the vascular subgroup (1399 participants). Neither trial reported the number of units of red cells transfused per participant up to 30 days. Three outcomes were associated with very low-certainty evidence due to the very wide confidence intervals (CIs) resulting from small study sizes and low number of events. These were: all-cause mortality up to 30 days; number of participants requiring an allogeneic blood transfusion up to 30 days; and risk of requiring a repeat procedure or operation due to bleeding. Tranexamic acid may have no effect on the risk of thromboembolic events up to 30 days (risk ratio (RR) 1.10, 95% CI 0.88 to 1.36; 1 trial, 1360 participants; low-certainty evidence due to imprecision). There is one large ongoing trial (8320 participants) comparing tranexamic acid versus placebo in people undergoing non-cardiac surgery who are at high risk of requiring a red cell transfusion. This aims to complete recruitment in April 2023. This trial has primary outcomes of proportion of participants transfused with red blood cells and incidence of venous thromboembolism (DVT or PE). Topical drug treatments Most trials of topical drug treatments were at high risk of bias due to their open-label design (compared with usual care, or liquids were compared with sponges). All of the trials were small, most were very small, and few reported clinically relevant outcomes in the postoperative period. Fibrin sealant versus usual care was the topical drug comparison with the largest number of participants (5 trials, 784 participants). The five trials that compared fibrin sealant with usual care were all at high risk of bias, due to the open-label trial design with no measures put in place to minimise reporting bias. All of the trials were funded by pharmaceutical companies. None of the five trials reported the number of red cells transfused per participant up to 30 days or the number of participants requiring an allogeneic blood transfusion up to 30 days. The other three outcomes were associated with very low-certainty evidence with wide confidence intervals due to small sample sizes and the low number of events, these were: all-cause mortality up to 30 days; risk of requiring a repeat procedure due to bleeding; and risk of thromboembolic disease up to 30 days. We identified one large trial (500 participants) comparing fibrin sealant versus usual care in participants undergoing abdominal aortic aneurysm repair, which has not yet started recruitment. This trial lists death due to arterial disease and reintervention rates as primary outcomes. AUTHORS' CONCLUSIONS Because of a lack of data, we are uncertain whether any systemic or topical treatments used to reduce bleeding due to major vascular surgery have an effect on: all-cause mortality up to 30 days; risk of requiring a repeat procedure or operation due to bleeding; number of red cells transfused per participant up to 30 days or the number of participants requiring an allogeneic blood transfusion up to 30 days. There may be no effect of tranexamic acid on the risk of thromboembolic events up to 30 days, this is important as there has been concern that this risk may be increased. Trials with sample size targets of thousands of participants and clinically relevant outcomes are needed, and we look forward to seeing the results of the ongoing trials in the future.
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Affiliation(s)
- Anair Beverly
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Giok Ong
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Catherine Kimber
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Josie Sandercock
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Nicky J Welton
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter Wicks
- Cardiac Anaesthesia and Intensive Care, University Hospital Southampton, Southampton, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
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12
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Abtahi M, Kargoshai AA, Shetabi H, Manafi A, Manafi N, Badrouj A. The Effect of Tranexamic Acid Local Injection on Bleeding during and after Tonsillectomy: A Double-Blind Randomized Placebo-Controlled Trial. World J Plast Surg 2023; 12:31-36. [PMID: 38226192 PMCID: PMC10788099 DOI: 10.61186/wjps.12.3.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 10/11/2023] [Indexed: 01/17/2024] Open
Abstract
Background Tonsillectomy-related bleeding is one of the most prevalent and potentially fatal complications of this common surgical procedure. We aimed to assess the effect of tranexamic acid (TXA) local injection on bleeding during and after tonsillectomy. Methods This double-blind, randomized placebo-controlled trial included 20 candidates for tonsillectomy referred to Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran, in 2022. The subjects were randomized into two groups. Ten patients received TXA on their left side and the other ten on their right side 10 min before surgery. Placebo was administered to the contralateral side. The primary outcome was the volume of blood loss during tonsillectomy and up to 24 hours post-tonsillectomy. The secondary outcomes were surgeon satisfaction (rated 0-10), hemodynamic complications (patients' heart rate (HR) and mean arterial pressure (MAP) were recorded every 10 min), and rebleeding. The duration of surgery was also noted. Results The mean age of the patients was 21.35 ± 3.16 years, of whom 8 (30%) were male and 12 (60%) were female. there was no significant difference between groups in terms of HR and MAP at any time point. The median of surgery duration did not differ significantly between the two groups; however, the surgeon satisfaction with the procedure was significantly higher with TXA compared to placebo. None of the patients developed hemodynamic complications, and rebleeding did not occur in any of the subjects. Conclusions TXA local injection was not superior to placebo in terms of bleeding control during and after tonsillectomy, hemodynamic complications, rebleeding, and surgery duration.
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Affiliation(s)
- Mojtaba Abtahi
- Department of Otorhinolaryngology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amir-Abbas Kargoshai
- Department of Otorhinolaryngology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamidreza Shetabi
- Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amir Manafi
- Department of Anesthesia, Detroit Medical Center, NorthStar Anesthesia, Detroit, MI
| | - Navid Manafi
- Department of Anesthesia, Detroit Medical Center, NorthStar Anesthesia, Detroit, MI
| | - Ali Badrouj
- Department of Otorhinolaryngology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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13
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Tran NT, Bar-Zeev S, Schulte-Hillen C, Zeck W. Tranexamic Acid for Postpartum Hemorrhage Treatment in Low-Resource Settings: A Rapid Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:7385. [PMID: 35742634 PMCID: PMC9223501 DOI: 10.3390/ijerph19127385] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/27/2022] [Accepted: 06/14/2022] [Indexed: 11/25/2022]
Abstract
Tranexamic acid (TXA) effectively reduces bleeding in women with postpartum hemorrhage (PPH) in hospital settings. To guide policies and practices, this rapid scoping review undertaken by two reviewers aimed to examine how TXA is utilized in lower-level maternity care settings in low-resource settings. Articles were searched in EMBASE, MEDLINE, Emcare, the Maternity and Infant Care Database, the Joanna Briggs Institute Evidence-Based Practice Database, and the Cochrane Library from January 2011 to September 2021. We included non-randomized and randomized research looking at the feasibility, acceptability, and health system implications in low- and lower-middle-income countries. Relevant information was retrieved using pre-tested forms. Findings were descriptively synthesized. Out of 129 identified citations, 23 records were eligible for inclusion, including 20 TXA effectiveness studies, two economic evaluations, and one mortality modeling. Except for the latter, all the studies were conducted in lower-middle-income countries and most occurred in tertiary referral hospitals. When compared to placebo or other medications, TXA was found effective in both treating and preventing PPH during vaginal and cesarean delivery. If made available in home and clinic settings, it can reduce PPH-related mortality. TXA could be cost-effective when used with non-surgical interventions to treat refractory PPH. Capacity building of service providers appears to need time-intensive training and supportive monitoring. No studies were exploring TXA acceptability from the standpoint of providers, as well as the implications for health governance and information systems. There is a scarcity of information on how to prepare the health system and services to incorporate TXA in lower-level maternity care facilities in low-resource settings. Implementation research is critically needed to assist practitioners and decision-makers in establishing a TXA-inclusive PPH treatment package to reduce PPH-related death and disability.
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Affiliation(s)
- Nguyen Toan Tran
- Australian Centre for Public and Population Health Research, Faculty of Health, University of Technology Sydney, Sydney, NSW 2007, Australia
- Faculty of Medicine, University of Geneva, 1211 Geneva, Switzerland
| | - Sarah Bar-Zeev
- United Nations Population Fund, Technical Division, New York, NY 10158, USA; (S.B.-Z.); (W.Z.)
| | | | - Willibald Zeck
- United Nations Population Fund, Technical Division, New York, NY 10158, USA; (S.B.-Z.); (W.Z.)
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14
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Shakur‐Still H, Grassin‐Delyle S, Muhunthan K, Ahmadzia HK, Faraoni D, Arribas M, Roberts I. Alternative routes to intravenous tranexamic acid for postpartum hemorrhage: A systematic search and narrative review. Int J Gynaecol Obstet 2022; 158 Suppl 1:40-45. [PMID: 35762806 PMCID: PMC9327714 DOI: 10.1002/ijgo.14201] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
OBJECTIVE To review available data on tranexamic acid (TXA) plasma concentration needed to inhibit fibrinolysis and the time to achieve this concentration when giving TXA by different routes in humans. To identify ongoing trials assessing alternatives to intravenous TXA administration. METHODS We updated two previous systematic reviews by searching MEDLINE, EMBASE, OviSP, and ISI Web of Science from database inception to July 2021. We also searched the WHO International Clinical Trials Registry Platform for ongoing trials to July 2021. Titles and abstracts were screened for relevant trials. Two reviewers independently reviewed and agreed the trials to be included. RESULTS Plasma TXA concentrations over 10 mg/L provide near maximal inhibition of fibrinolysis, with concentrations over 5 mg/L providing partial inhibition. Oral TXA tablets take about 1 h to reach a plasma concentration of 5 mg/L in postpartum women. Studies in healthy volunteers and shocked trauma patients show that intramuscular TXA achieves a plasma level of over 10 mg/L within 15 min. One trial is ongoing to determine the pharmacokinetics of intramuscular and oral solution TXA in pregnant women. CONCLUSION Intramuscular TXA in healthy volunteers and shocked trauma patients reaches therapeutic concentration rapidly. Oral TXA tablets take too long to reach the minimum therapeutic concentration in postpartum women.
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Affiliation(s)
| | - Stanislas Grassin‐Delyle
- Département des maladies des voies respiratoiresHôpital FochSuresnesFrance
- Infection et inflammation, Département de Biotechnologie de la Santé, UVSQ, INSERMUniversité Paris‐SaclayMontigny le BretonneuxFrance
| | | | - Homa K. Ahmadzia
- Department of Obstetrics and Gynecology, Division of Maternal‐Fetal MedicineGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - David Faraoni
- Department of Anesthesiology, Perioperative and Pain Medicine, Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Texas Children’s HospitalBaylor College of MedicineHoustonTexasUSA
| | - Monica Arribas
- Clinical Trials UnitLondon School of Hygiene and Tropical MedicineLondonUK
| | - Ian Roberts
- Clinical Trials UnitLondon School of Hygiene and Tropical MedicineLondonUK
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15
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Wothe JK, Elfstrand E, Mooney MR, Wothe DD. Rotational Thromboelastometry-Guided Venoarterial Extracorporeal Membrane Oxygenation in the Treatment of Amniotic Fluid Embolism. Case Rep Obstet Gynecol 2022; 2022:9658708. [PMID: 35646404 PMCID: PMC9132692 DOI: 10.1155/2022/9658708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 03/27/2022] [Accepted: 05/05/2022] [Indexed: 11/17/2022] Open
Abstract
Amniotic fluid embolism (AFE) is a rare and often fatal complication of pregnancy that occurs during the puerperium. The low incidence of AFE has resulted in few large studies, which makes evidence-based management of AFE challenging. The use of extracorporeal membrane oxygenation (ECMO) has been reported but is limited by availability and challenges managing anticoagulation. In this report, we detail the case of a 29-year-old female who suffered from an AFE leading to cardiac arrest and disseminated intravascular coagulopathy. She was treated with protocolized A-OK (adenosine, ondansetron, and ketorolac), emergency c-section, cardiopulmonary resuscitation, massive blood transfusion, and rotational thromboelastometry-guided ECMO, allowing her to forgo initial anticoagulation. After a prolonged rehabilitation with initial poor neurological status, she made a complete recovery. In this report, we describe the protocols that contributed to her recovery and detail management of complicated AFE for other clinicians.
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Affiliation(s)
- Jillian K. Wothe
- University of Minnesota, Medical School, 420 Delaware St SE Minneapolis, MN, 55455, USA
| | - Elizabeth Elfstrand
- Abbott Northwestern, Department of Obstetrics and Gynecology, 800 E 28th St Minneapolis, MN 55407, USA
| | - Michael R. Mooney
- Abbott Northwestern Department of Cardiology, 800 E 28th St Minneapolis, MN 55407, USA
| | - Donald D. Wothe
- Abbott Northwestern, Department of Obstetrics and Gynecology, 800 E 28th St Minneapolis, MN 55407, USA
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16
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Helmer P, Schlesinger T, Hottenrott S, Papsdorf M, Wöckel A, Sitter M, Skazel T, Wurmb T, Türkmeneli I, Härtel C, Hofer S, Alkatout I, Messroghli L, Girard T, Meybohm P, Kranke P. [Postpartum hemorrhage : Interdisciplinary consideration in the context of patient blood management]. Anaesthesist 2022; 71:181-189. [PMID: 35244736 DOI: 10.1007/s00101-022-01098-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2021] [Indexed: 12/20/2022]
Abstract
Postpartum hemorrhage (PPH) nowadays still represents a severe complication of both a vaginal delivery and a cesarean section. In German-speaking areas a new definition of the term has recently become established and the nomenclature with respect to the severe form of PPH was dropped. The handling of misoprostol as a uterotonic during treatment of PPH is also new, which is available in Germany only as a medical direct import. For adequate diagnostics and targeted treatment interdisciplinary and standardized algorithms should be established and the specialist disciplines involved should be sensitized to this problem. In addition to an adequate hemostasis, a developing coagulopathy must be recognized at an early stage and treated with targeted coagulation management. Through implementation concepts, particularly the second pillar (minimization of blood loss) and the third pillar (rational use of blood transfusions) of patient blood management, various aspects for improvement of treatment of a PPH can be identified.
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Affiliation(s)
- Philipp Helmer
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Tobias Schlesinger
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Sebastian Hottenrott
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Michael Papsdorf
- Frauenklinik und Poliklinik, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Achim Wöckel
- Frauenklinik und Poliklinik, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Magdalena Sitter
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Tobias Skazel
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Thomas Wurmb
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Ismail Türkmeneli
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Christoph Härtel
- Kinderklinik und Poliklinik, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Stefan Hofer
- Klinik für Anästhesie, Intensiv‑, Notfallmedizin und Schmerztherapie, Westpfalz-Klinikum, Kaiserslautern, Deutschland
| | - Ibrahim Alkatout
- Klinik für Gynäkologie und Geburtshilfe (Frauenheilkunde), Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland
| | - Leila Messroghli
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Frankfurt am Main, Deutschland
| | - Thierry Girard
- Anästhesiologie, Universitätsspital Basel, Basel, Schweiz
| | - Patrick Meybohm
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Peter Kranke
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
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17
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Aziz S, Rossiter S, Homer CSE, Wilson AN, Comrie‐Thomson L, Scott N, Vogel JP. The cost-effectiveness of tranexamic acid for treatment of postpartum hemorrhage: A systematic review. Int J Gynaecol Obstet 2021; 155:331-344. [PMID: 33621351 PMCID: PMC8596845 DOI: 10.1002/ijgo.13654] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/02/2021] [Accepted: 02/22/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Postpartum hemorrhage (PPH) is responsible for nearly one quarter of maternal deaths. A 2017 multicountry trial found that incorporating tranexamic acid (TXA) into the PPH management package was effective in reducing maternal death due to bleeding. OBJECTIVE To systematically review studies assessing the cost-effectiveness of tranexamic acid for PPH treatment. SEARCH STRATEGY Nine databases were searched using variations of keywords 'tranexamic acid', 'postpartum hemorrhage' and 'cost effectiveness'. SELECTION CRITERIA Eligible studies were any type of economic or effectiveness evaluation studies on tranexamic acid for treating women with PPH. DATA COLLECTION AND ANALYSIS Two reviewers independently screened citations and extracted data on cost effectiveness measures. Quality was assessed using the Consensus on Health Economic Criteria list. MAIN RESULTS Four studies were included, of which two were abstracts. Three studies concluded that early administration of TXA was cost-saving or cost-effective. One abstract reported TXA was not cost-effective in the USA unless the probability of death due to hemorrhage is higher. CONCLUSION Available evidence (four studies in three countries) suggests that this life-saving intervention may be below willingness to pay thresholds (cost-effective) or cost saving. Further studies conducted in different populations and settings are needed to inform health policy decision-making to reduce PPH-associated morbidity and mortality.
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Affiliation(s)
- Samia Aziz
- Maternal, Child and Adolescent Health ProgramBurnet InstituteMelbourneVic.Australia
- School of Population and Global HealthThe University of MelbourneMelbourneVic.Australia
| | - Shania Rossiter
- Maternal, Child and Adolescent Health ProgramBurnet InstituteMelbourneVic.Australia
- School of Population and Global HealthThe University of MelbourneMelbourneVic.Australia
| | - Caroline S. E. Homer
- Maternal, Child and Adolescent Health ProgramBurnet InstituteMelbourneVic.Australia
| | - Alyce N. Wilson
- Maternal, Child and Adolescent Health ProgramBurnet InstituteMelbourneVic.Australia
- Nossal Institute for Global HealthMelbourne School of Population and Global HealthUniversity of MelbourneMelbourneVic.Australia
| | - Liz Comrie‐Thomson
- Maternal, Child and Adolescent Health ProgramBurnet InstituteMelbourneVic.Australia
- School of Public Health and Preventive MedicineMonash UniversityMelbourneVic.Australia
- Faculty of Medicine and Health SciencesGhent UniversityGhentBelgium
| | - Nick Scott
- Maternal, Child and Adolescent Health ProgramBurnet InstituteMelbourneVic.Australia
| | - Joshua P. Vogel
- Maternal, Child and Adolescent Health ProgramBurnet InstituteMelbourneVic.Australia
- Nossal Institute for Global HealthMelbourne School of Population and Global HealthUniversity of MelbourneMelbourneVic.Australia
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Fuzi J, Budiono GR, Meller C, Jacobson I. Tranexamic acid in otorhinolaryngology - A contemporary review. World J Otorhinolaryngol Head Neck Surg 2021; 7:328-337. [PMID: 34632348 PMCID: PMC8486689 DOI: 10.1016/j.wjorl.2020.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/13/2020] [Accepted: 05/26/2020] [Indexed: 11/25/2022] Open
Abstract
Tranexamic acid (TXA) is an anti-fibrinolytic agent which has been proven beneficial in multiple surgical specialties where significant bleeding can occur. Whilst it has been widely available for over 40 years its use within Otorhinolaryngology is still limited. Operations in Otorhinolaryngology are particularly varied with some such as tonsillectomy having the potential for significant life threatening bleeding. Other operations are performed within small confined surgical fields and even small amounts of bleeding can significantly detriment surgical field and increase technical difficulty and operative time. This review evaluated the current literature on the benefits of tranexamic acid within the field of Otorhinolaryngology and Head and Neck Surgery. Overall TXA was demonstrated to be a safe drug with no major adverse effects including thromboembolic events reported in any study. It has been shown to be of particular benefit in rhinology by improving surgical field, reducing operative time and reducing postoperative swelling and ecchymosis. The benefit in tonsillectomy is less clear and further studies are required to evaluate its potential use in the reduction of post tonsillectomy haemorrhage rates.
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Affiliation(s)
- Jordan Fuzi
- Department of Otolaryngology, Head and Neck Surgery, Prince of Wales Hospital, New South Wales, Australia
| | | | - Catherine Meller
- Department of Otolaryngology, Head and Neck Surgery, Prince of Wales Hospital, New South Wales, Australia
| | - Ian Jacobson
- Department of Otolaryngology, Head and Neck Surgery, Prince of Wales Hospital, New South Wales, Australia
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Shander A, Javidroozi M, Sentilhes L. Tranexamic acid and obstetric hemorrhage: give empirically or selectively? Int J Obstet Anesth 2021; 48:103206. [PMID: 34343820 DOI: 10.1016/j.ijoa.2021.103206] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 06/09/2021] [Accepted: 06/26/2021] [Indexed: 11/30/2022]
Abstract
Antifibrinolytic agents such as tranexamic acid (TXA) inhibit the fibrinolytic pathway and protect blood clots from being degraded, thereby promoting hemostasis. They have been used to reduce blood loss in various settings including obstetrics. Based on current evidence, TXA can be considered as a therapeutic adjunct to control postpartum hemorrhage (PPH) after vaginal and cesarean deliveries, with earlier administration preferred. This strategy has been demonstrated to reduce mortality due to bleeding (but not the incidence of transfusion) in developing countries. On the other hand, the benefit-risk ratio of TXA has not been fully assessed in developed countries which have much lower PPH-related mortality rates and better access to other management modalities. As a proposed prophylactic agent to prevent PPH, the level of evidence is currently insufficient to recommend the routine use of TXA to prevent blood loss after vaginal and cesarean deliveries. The results of large new multicenter studies assessing the impact of TXA on maternal blood loss-related outcomes after cesarean delivery are awaited. While most studies to date have focused on empirical and one-size-fit-all dosing of TXA, more selective and individualized treatment protocols (possibly guided by functional coagulation assays) are needed to pave the way for safer and more effective use of this inexpensive and widely used medication.
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Affiliation(s)
- A Shander
- Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Hospital and Medical Center, Englewood, NJ, USA.
| | - M Javidroozi
- Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Hospital and Medical Center, Englewood, NJ, USA
| | - L Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
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20
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Moore EE, Moore HB, Kornblith LZ, Neal MD, Hoffman M, Mutch NJ, Schöchl H, Hunt BJ, Sauaia A. Trauma-induced coagulopathy. Nat Rev Dis Primers 2021; 7:30. [PMID: 33927200 PMCID: PMC9107773 DOI: 10.1038/s41572-021-00264-3] [Citation(s) in RCA: 306] [Impact Index Per Article: 102.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2021] [Indexed: 12/12/2022]
Abstract
Uncontrolled haemorrhage is a major preventable cause of death in patients with traumatic injury. Trauma-induced coagulopathy (TIC) describes abnormal coagulation processes that are attributable to trauma. In the early hours of TIC development, hypocoagulability is typically present, resulting in bleeding, whereas later TIC is characterized by a hypercoagulable state associated with venous thromboembolism and multiple organ failure. Several pathophysiological mechanisms underlie TIC; tissue injury and shock synergistically provoke endothelial, immune system, platelet and clotting activation, which are accentuated by the 'lethal triad' (coagulopathy, hypothermia and acidosis). Traumatic brain injury also has a distinct role in TIC. Haemostatic abnormalities include fibrinogen depletion, inadequate thrombin generation, impaired platelet function and dysregulated fibrinolysis. Laboratory diagnosis is based on coagulation abnormalities detected by conventional or viscoelastic haemostatic assays; however, it does not always match the clinical condition. Management priorities are stopping blood loss and reversing shock by restoring circulating blood volume, to prevent or reduce the risk of worsening TIC. Various blood products can be used in resuscitation; however, there is no international agreement on the optimal composition of transfusion components. Tranexamic acid is used in pre-hospital settings selectively in the USA and more widely in Europe and other locations. Survivors of TIC experience high rates of morbidity, which affects short-term and long-term quality of life and functional outcome.
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Affiliation(s)
- Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO, USA.
- Department of Surgery, University of Colorado Denver, Aurora, CO, USA.
| | - Hunter B Moore
- Department of Surgery, University of Colorado Denver, Aurora, CO, USA
| | - Lucy Z Kornblith
- Trauma and Surgical Critical Care, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Matthew D Neal
- Pittsburgh Trauma Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Maureane Hoffman
- Duke University School of Medicine, Transfusion Service, Durham VA Medical Center, Durham, NC, USA
| | - Nicola J Mutch
- Aberdeen Cardiovascular & Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Herbert Schöchl
- Department of Anesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg and Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | | | - Angela Sauaia
- Department of Surgery, University of Colorado Denver, Aurora, CO, USA
- Colorado School of Public Health, University of Colorado Denver, Aurora, CO, USA
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21
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Downe S, Calleja Agius J, Balaam MC, Frith L. Understanding childbirth as a complex salutogenic phenomenon: The EU COST BIRTH Action Special Collection. PLoS One 2020; 15:e0236722. [PMID: 32756586 PMCID: PMC7406045 DOI: 10.1371/journal.pone.0236722] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
In 2014, the EU funded a four-year European Cooperation in Science and Technology (COST) Action to address the topic of childbirth. The COST Birth Action was a cross-European network, that brought together over 120 scientists, practitioners, activists and policy makers from 34 countries to work on intrapartum care. The central aim was to advance the state of research and practice in a specific area of great clinical and social importance, intrapartum care. The Action used inter and trans-disciplinary approaches to address birth from multiple perspectives and drew on complexity theory and the concept of salutogenesis (wellbeing). This special collection presents six papers produced from the Action and gives a sense of the range and depth of the work conducted. The Collection illustrates the knowledge that can be generated when a diverse group of people come together with a similar goals and perspectives.
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Affiliation(s)
- Soo Downe
- ReaCH Group, UCLan, Lancashire, United Kingdom
| | - Jean Calleja Agius
- Department of Anatomy, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | | | - Lucy Frith
- Institute of Population Health, University of Liverpool, Liverpool, United Kingdom
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Beverly A, Ong G, Doree C, Welton NJ, Estcourt LJ. Drugs to reduce bleeding and transfusion in major open vascular or endovascular surgery: a systematic review and network meta-analysis. Hippokratia 2020. [DOI: 10.1002/14651858.cd013649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Anair Beverly
- Systematic Review Initiative; NHS Blood and Transplant; Oxford UK
| | - Giok Ong
- Systematic Review Initiative; NHS Blood and Transplant; Oxford UK
| | - Carolyn Doree
- Systematic Review Initiative; NHS Blood and Transplant; Oxford UK
| | - Nicky J Welton
- Population Health Sciences, Bristol Medical School; University of Bristol; Bristol UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine; NHS Blood and Transplant; Oxford UK
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Kellie FJ, Wandabwa JN, Mousa HA, Weeks AD. Mechanical and surgical interventions for treating primary postpartum haemorrhage. Cochrane Database Syst Rev 2020; 7:CD013663. [PMID: 32609374 PMCID: PMC8407481 DOI: 10.1002/14651858.cd013663] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Primary postpartum haemorrhage (PPH) is commonly defined as bleeding from the genital tract of 500 mL or more within 24 hours of birth. It is one of the most common causes of maternal mortality worldwide and causes significant physical and psychological morbidity. An earlier Cochrane Review considering any treatments for the management of primary PPH, has been split into separate reviews. This review considers treatment with mechanical and surgical interventions. OBJECTIVES To determine the effectiveness and safety of mechanical and surgical interventions used for the treatment of primary PPH. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (26 July 2019) and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials (RCTs) of mechanical/surgical methods for the treatment of primary PPH compared with standard care or another mechanical/surgical method. Interventions could include uterine packing, intrauterine balloon insertion, artery ligation/embolism, or uterine compression (either with sutures or manually). We included studies reported in abstract form if there was sufficient information to permit risk of bias assessment. Trials using a cluster-RCT design were eligible for inclusion, but quasi-RCTs or cross-over studies were not. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion and risk of bias, independently extracted data and checked data for accuracy. We used GRADE to assess the certainty of the evidence. MAIN RESULTS We included nine small trials (944 women) conducted in Pakistan, Turkey, Thailand, Egypt (four trials), Saudi Arabia, Benin and Mali. Overall, included trials were at an unclear risk of bias. Due to substantial differences between the studies, it was not possible to combine any trials in meta-analysis. Many of this review's important outcomes were not reported. GRADE assessments ranged from very low to low, with the majority of outcome results rated as very low certainty. Downgrading decisions were mainly based on study design limitations and imprecision; one study was also downgraded for indirectness. External uterine compression versus normal care (1 trial, 64 women) Very low-certainty evidence means that we are unclear about the effect on blood transfusion (risk ratio (RR) 2.33, 95% confidence interval (CI) 0.66 to 8.23). Uterine arterial embolisation versus surgical devascularisation plus B-Lynch (1 trial, 23 women) The available evidence for hysterectomy to control bleeding (RR 0.73, 95% CI 0.15 to 3.57) is unclear due to very low-certainty evidence. The available evidence for intervention side effects is also unclear because the evidence was very low certainty (RR 1.09; 95% CI 0.08 to 15.41). Intrauterine Tamponade Studies included various methods of intrauterine tamponade: the commercial Bakri balloon, a fluid-filled condom-loaded latex catheter ('condom catheter'), an air-filled latex balloon-loaded catheter ('latex balloon catheter'), or traditional packing with gauze. Balloon tamponade versus normal care (2 trials, 356 women) One study(116 women) used the condom catheter. This study found that it may increase blood loss of 1000 mL or more (RR 1.52, 95% CI 1.15 to 2.00; 113 women), very low-certainty evidence. For other outcomes the results are unclear and graded as very low-certainty evidence: mortality due to bleeding (RR 6.21, 95% CI 0.77 to 49.98); hysterectomy to control bleeding (RR 4.14, 95% CI 0.48 to 35.93); total blood transfusion (RR 1.49, 95% CI 0.88 to 2.51); and side effects. A second study of 240 women used the latex balloon catheter together with cervical cerclage. Very low-certainty evidence means we are unclear about the effect on hysterectomy (RR 0.14, 95% CI 0.01 to 2.74) and additional surgical interventions to control bleeding (RR 0.20, 95% CI 0.01 to 4.12). Bakri balloon tamponade versus haemostatic square suturing of the uterus (1 trial, 13 women) In this small trial there was no mortality due to bleeding, serious maternal morbidity or side effects of the intervention, and the results are unclear for blood transfusion (RR 0.57, 95% CI 0.14 to 2.36; very low certainty). Bakri balloon tamponade may reduce mean 'intraoperative' blood loss (mean difference (MD) -426 mL, 95% CI -631.28 to -220.72), very low-certainty evidence. Comparison of intrauterine tamponade methods (3 trials, 328 women) One study (66 women) compared the Bakri balloon and the condom catheter, but it was uncertain whether the Bakri balloon reduces the risk of hysterectomy to control bleeding due to very low-certainty evidence (RR 0.50, 95% CI 0.05 to 5.25). Very low-certainty evidence also means we are unclear about the results for the risk of blood transfusion (RR 0.97, 95% CI 0.88 to 1.06). A second study (50 women) compared Bakri balloon, with and without a traction stitch. Very low-certainty evidence means we are unclear about the results for hysterectomy to control bleeding (RR 0.20, 95% CI 0.01 to 3.97). A third study (212 women) compared the condom catheter to gauze packing and found that it may reduce fever (RR 0.47, 95% CI 0.38 to 0.59), but again the evidence was very low certainty. Modified B-Lynch compression suture versus standard B-Lynch compression suture (1 trial, 160 women) Low-certainty evidence suggests that a modified B-Lynch compression suture may reduce the risk of hysterectomy to control bleeding (RR 0.33, 95% CI 0.11 to 0.99) and postoperative blood loss (MD -244.00 mL, 95% CI -295.25 to -192.75). AUTHORS' CONCLUSIONS There is currently insufficient evidence from RCTs to determine the relative effectiveness and safety of mechanical and surgical interventions for treating primary PPH. High-quality randomised trials are urgently needed, and new emergency consent pathways should facilitate recruitment. The finding that intrauterine tamponade may increase total blood loss > 1000 mL suggests that introducing condom-balloon tamponade into low-resource settings on its own without multi-system quality improvement does not reduce PPH deaths or morbidity. The suggestion that modified B-Lynch suture may be superior to the original requires further research before the revised technique is adopted. In high-resource settings, uterine artery embolisation has become popular as the equipment and skills become more widely available. However, there is little randomised trial evidence regarding efficacy and this requires further research. We urge new trial authors to adopt PPH core outcomes to facilitate consistency between primary studies and subsequent meta-analysis.
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Affiliation(s)
- Frances J Kellie
- Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
| | - Julius N Wandabwa
- Department of Obstetrics and Gynaecology, Busitema University, Mbale, Uganda
| | - Hatem A Mousa
- University Department of Obstetrics and Gynaecology, Fetal and Maternal Medicine Unit, Leicester Royal Infirmary, Leicester, UK
| | - Andrew D Weeks
- Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
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Ghaffarpasand F, Abbasi HR, Bolandparvaz S, Paydar S, Dehghankhalili M. Tranexamic Acid; A Glittering Player in the Field of Trauma. Bull Emerg Trauma 2020; 8:53-55. [PMID: 32420388 PMCID: PMC7211392 DOI: 10.30476/beat.2020.46443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Fariborz Ghaffarpasand
- Research Center for Neuromodulation and Pain, Shiraz University of Medical Sciences, Shiraz, Iran.,Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Reza Abbasi
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Shahram Paydar
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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25
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Diop A, Abbas D, Ngoc NTN, Martin R, Razafi A, Tuyet HTD, Winikoff B. A double-blind, randomized controlled trial to explore oral tranexamic acid as adjunct for the treatment for postpartum hemorrhage. Reprod Health 2020; 17:34. [PMID: 32143721 PMCID: PMC7060559 DOI: 10.1186/s12978-020-0887-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 02/18/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Oral tranexamic acid (TXA), if effective in reducing blood loss after delivery for women experiencing primary PPH, could be administered where parenteral administration is not feasible. This trial assessed the efficacy, safety, and acceptability of oral TXA when used as an adjunct to sublingual misoprostol to treat postpartum hemorrhage (PPH) following vaginal delivery. METHODS From October 2016 to January 2018, women presenting at four hospitals in Senegal and Vietnam for vaginal delivery were screened for enrollment in the trial. Women diagnosed with postpartum hemorrhage (defined as blood loss ≥700 ml) were randomized to receive either oral TXA (1950 mg) or placebo in addition to 800 mcg sublingual misoprostol. Postpartum blood loss was measured using a calibrated drape. Blood loss for all PPH cases was recorded for 2 h after administration of the drugs. The primary outcome measure was the proportion of women with bleeding controlled with the trial regimen without recourse to further treatment. Secondary outcomes including the rate of severe PPH, mean/median blood loss, use of additional uterotonics and/or interventions side effects, and acceptability were also recorded. RESULTS Of the 258 women who received treatment for PPH, 128 received placebo and misoprostol and 130 received TXA and misoprostol. The proportion of women who had active bleeding controlled with trial drugs alone and no additional interventions was similar in both groups: 77(60.2%) placebo; 74 (56.9%) TXA, p = 0.59). Use of other interventions to control bleeding, including uterotonics, did not differ significantly between groups. Median blood loss at PPH diagnosis was 700 ml in both groups. Uterine atony alone or in addition to another cause contributed to over 90% of PPH cases reported (92.2% placebo vs. 91.5% TXA), other causes included perineal and cervical lacerations and retained placenta. Reports of side effects and acceptability were similar in the two groups. CONCLUSION Adjunct use of oral TXA with misoprostol to treat PPH resulted in similar clinical and acceptability outcomes when compared to treatment with misoprostol alone. TRIAL REGISTRATION This trial was registered with ClinicalTrials.gov, number NCT02805426. Registered on 3 September 2016.
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Affiliation(s)
- Ayisha Diop
- Gynuity Health Projects, 220 E. 42nd Street Suite 710, New York, NY 10017 USA
| | - Dina Abbas
- Gynuity Health Projects, 220 E. 42nd Street Suite 710, New York, NY 10017 USA
| | - Nguyen thi Nhu Ngoc
- Center for Research and Consultancy in Reproductive Health (CRCRH), 38A Nguyễn Lâm. Ward 6 District 10, Ho Chi Minh City, Vietnam
| | - Roxanne Martin
- Gynuity Health Projects, 220 E. 42nd Street Suite 710, New York, NY 10017 USA
| | - Ange Razafi
- Maternité Hopital Regional El Hadji Ahmadou Sakhir Ndieguene De Thiès, Thiès, Senegal
| | | | - Beverly Winikoff
- Gynuity Health Projects, 220 E. 42nd Street Suite 710, New York, NY 10017 USA
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26
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Cai J, Ribkoff J, Olson S, Raghunathan V, Al-Samkari H, DeLoughery TG, Shatzel JJ. The many roles of tranexamic acid: An overview of the clinical indications for TXA in medical and surgical patients. Eur J Haematol 2019; 104:79-87. [PMID: 31729076 DOI: 10.1111/ejh.13348] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 11/08/2019] [Accepted: 11/09/2019] [Indexed: 12/14/2022]
Abstract
Clinically significant bleeding can occur as a consequence of surgery, trauma, obstetric complications, anticoagulation, and a wide variety of disorders of hemostasis. As the causes of bleeding are diverse and not always immediately apparent, the availability of a safe, effective, and non-specific hemostatic agent is vital in a wide range of clinical settings, with antifibrinolytic agents often utilized for this purpose. Tranexamic acid (TXA) is one of the most commonly used and widely researched antifibrinolytic agents; its role in postpartum hemorrhage, menorrhagia, trauma-associated hemorrhage, and surgical bleeding has been well defined. However, the utility of TXA goes beyond these common indications, with accumulating data suggesting its ability to reduce bleeding and improve clinical outcomes in the face of many different hemostatic challenges, without a clear increase in thrombotic risk. Herein, we review the literature and provide practical suggestions for clinical use of TXA across a broad spectrum of bleeding disorders.
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Affiliation(s)
- Johnny Cai
- Department of Internal Medicine, Oregon Health and Science University, Portland, Oregon
| | - Jessica Ribkoff
- School of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Sven Olson
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Vikram Raghunathan
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Thomas G DeLoughery
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Joseph J Shatzel
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
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Zehtabchi S. TXA plus compression and nasal packing did not differ for epistaxis, and both were better than compression alone. Ann Intern Med 2019; 171:JC41. [PMID: 31610554 DOI: 10.7326/acpj201910150-041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Shahriar Zehtabchi
- State University of New York, Downstate Medical CenterNew York, New York, USA
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28
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Zehtabchi S. Review: In nonsurgical settings, tranexamic acid reduces mortality and does not increase thrombotic events. Ann Intern Med 2019; 171:JC40. [PMID: 31610553 DOI: 10.7326/acpj201910150-040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Shahriar Zehtabchi
- State University of New York, Downstate Medical CenterNew York, New York, USA
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29
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Beverly A, Ong G, Wilkinson KL, Doree C, Welton NJ, Estcourt LJ. Drugs to reduce bleeding and transfusion in adults undergoing cardiac surgery: a systematic review and network meta-analysis. Hippokratia 2019. [DOI: 10.1002/14651858.cd013427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Anair Beverly
- NHS Blood and Transplant; Systematic Review Initiative; Oxford UK
| | - Giok Ong
- NHS Blood and Transplant; Systematic Review Initiative; Oxford UK
| | - Kirstin L Wilkinson
- Southampton University NHS Hospital; Paediatric and Adult Cardiothoracic Anaesthesia; Tremona Road Southampton UK SO16 6YD
| | - Carolyn Doree
- NHS Blood and Transplant; Systematic Review Initiative; Oxford UK
| | - Nicky J Welton
- University of Bristol; Population Health Sciences, Bristol Medical School; Bristol UK
| | - Lise J Estcourt
- NHS Blood and Transplant; Haematology/Transfusion Medicine; Level 2, John Radcliffe Hospital Headington Oxford UK OX3 9BQ
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30
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Bottom-up development of national obstetric guidelines in middle-income country Suriname. BMC Health Serv Res 2019; 19:651. [PMID: 31500615 PMCID: PMC6734520 DOI: 10.1186/s12913-019-4377-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/29/2019] [Indexed: 11/16/2022] Open
Abstract
Background Obstetric guidelines are useful to improve the quality of care. Availability of international guidelines has rapidly increased, however the contextualization to enhance feasibility of implementation in health facilities in low and middle-income settings has only been described in literature in a few instances. This study describes the approach and lessons learned from the ‘bottom-up’ development process of context-tailored national obstetric guidelines in middle-income country Suriname. Methods Local obstetric health care providers initiated the guideline development process in Suriname in August 2016 for two common obstetric conditions: hypertensive disorders of pregnancy (HDP) and post partum haemorrhage (PPH). Results The process consisted of six steps: (1) determination of how and why women died, (2) interviews and observations of local clinical practice, (3) review of international guidelines, (4) development of a primary set of guidelines, (5) initiation of a national discussion on the guidelines content and (6) establishment of the final guidelines based on consensus. Maternal enquiry of HDP- and PPH-related maternal deaths revealed substandard care in 90 and 95% of cases, respectively. An assessment of the management through interviews and labour observations identified gaps in quality of the provided care and large discrepancies in the management of HDP and PPH between the hospitals. International recommendations were considered unfeasible and were inconsistent when compared to each other. Local health care providers and stakeholders convened to create national context-tailored guidelines based on adapted international recommendations. The guidelines were developed within four months and locally implemented. Conclusion Development of national context-tailored guidelines is achievable in a middle-income country when using a ‘bottom-up’ approach that involves all obstetric health care providers and stakeholders in the earliest phase. We hope the descriptive process of guideline development is helpful for other countries in need of nationwide guidelines. Electronic supplementary material The online version of this article (10.1186/s12913-019-4377-6) contains supplementary material, which is available to authorized users.
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31
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Vogel JP, Dowswell T, Lewin S, Bonet M, Hampson L, Kellie F, Portela A, Bucagu M, Norris SL, Neilson J, Gülmezoglu AM, Oladapo OT. Developing and applying a 'living guidelines' approach to WHO recommendations on maternal and perinatal health. BMJ Glob Health 2019; 4:e001683. [PMID: 31478014 PMCID: PMC6703290 DOI: 10.1136/bmjgh-2019-001683] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/27/2019] [Accepted: 06/29/2019] [Indexed: 01/07/2023] Open
Abstract
How should the WHO most efficiently keep its global recommendations up to date? In this article we describe how WHO developed and applied a 'living guidelines' approach to its maternal and perinatal health (MPH) recommendations, based on a systematic and continuous process of prioritisation and updating. Using this approach, 25 new or updated WHO MPH recommendations have been published in 2017-2018. The new approach helps WHO ensure its guidance is responsive to emerging evidence and remains up to date for end users.
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Affiliation(s)
- Joshua P Vogel
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
- Maternal and Child Health Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Therese Dowswell
- Cochrane Pregnancy and Childbirth, University of Liverpool, Liverpool, UK
| | - Simon Lewin
- Division of Health Services and Centre for Informed Health Choices, Norwegian Institute of Public Health, Oslo, Norway
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- Cochrane Effective Practice and Organisation of Care, Norwegian Institute of Public Health, Oslo, Norway
| | - Mercedes Bonet
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Lynn Hampson
- Cochrane Pregnancy and Childbirth, University of Liverpool, Liverpool, UK
| | - Frances Kellie
- Cochrane Pregnancy and Childbirth, University of Liverpool, Liverpool, UK
| | - Anayda Portela
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Maurice Bucagu
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Susan L Norris
- Department of Information, Evidence and Research, World Health Organization, Geneva, Switzerland
| | - James Neilson
- Cochrane Pregnancy and Childbirth, University of Liverpool, Liverpool, UK
| | - Ahmet Metin Gülmezoglu
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Olufemi T Oladapo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Brenner A, Ker K, Shakur-Still H, Roberts I. Tranexamic acid for post-partum haemorrhage: What, who and when. Best Pract Res Clin Obstet Gynaecol 2019; 61:66-74. [PMID: 31128974 PMCID: PMC6891248 DOI: 10.1016/j.bpobgyn.2019.04.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 04/18/2019] [Accepted: 04/23/2019] [Indexed: 01/08/2023]
Abstract
Tranexamic acid reduces bleeding by inhibiting the breakdown of blood clots. It is cost-effective and heat-stable with a long shelf life. In the WOMAN trial, tranexamic acid reduced deaths due to bleeding with no increase in thromboembolic events. The effect was greatest when women received tranexamic acid within 3 h of childbirth (RR = 0.69, 95% CI 0.52-0.91). The WHO recommends that women with post-partum haemorrhage receive 1 g tranexamic acid intravenously as soon as possible after giving birth, followed by a second dose if bleeding continues after 30 min or restarts within 24 h since the first dose. Urgent treatment is critical because women with post-partum haemorrhage bleed to death quickly, and tranexamic acid is most effective when given early. Evidence suggests there is no benefit when the drug is given more than 3 h after bleeding onset. Alternative routes of administration and use of tranexamic acid in the prevention of post-partum haemorrhage are research priorities.
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Affiliation(s)
- Amy Brenner
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom.
| | - Katharine Ker
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom.
| | - Haleema Shakur-Still
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom.
| | - Ian Roberts
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom.
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Xu P, Huang M. Small Peptides as Modulators of Serine Proteases. Curr Med Chem 2018; 27:3686-3705. [PMID: 30332941 DOI: 10.2174/0929867325666181016163630] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 09/26/2018] [Accepted: 10/09/2018] [Indexed: 02/08/2023]
Abstract
Serine proteases play critical roles in many physiological and pathological processes, and are proven diagnostic and therapeutic targets in a number of clinical indications. Suppression of the aberrant proteolytic activities of these proteases has been clinically used for the treatments of relevant diseases. Polypeptides with 10-20 residues are of great interests as medicinal modulators of serine proteases, because these peptides demonstrate the characteristics of both small molecule drugs and macromolecular drugs. In this review, we summarized the recent development of peptide-based inhibitors against serine proteases with potent inhibitory and high specificity comparable to monoclonal antibodies. In addition, we also discussed the strategies of enhancing plasma half-life and bioavailability of peptides in vivo, which is the main hurdle that limits the clinical translation of peptide-based drugs. This review advocates new avenue for the development of effective serine protease inhibitors and highlights the prospect of the medicinal use of these inhibitors.
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Affiliation(s)
- Peng Xu
- College of Biological Science and Engineering, Fuzhou University, Fuzhou, Fujian 350116, China
| | - Mingdong Huang
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350116, China
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Shakur H, Beaumont D, Pavord S, Gayet‐Ageron A, Ker K, Mousa HA. Antifibrinolytic drugs for treating primary postpartum haemorrhage. Cochrane Database Syst Rev 2018; 2:CD012964. [PMID: 29462500 PMCID: PMC6491317 DOI: 10.1002/14651858.cd012964] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Postpartum haemorrhage (PPH) - heaving bleeding within the first 24 hours after giving birth - is one of the main causes of death of women after childbirth. Antifibrinolytics, primarily tranexamic acid (TXA), have been shown to reduce bleeding in surgery and safely reduces mortality in trauma patients with bleeding without increasing the risk of adverse events.An earlier Cochrane review on treatments for primary PPH covered all the various available treatments - that review has now been split by types of treatment. This new review concentrates only on the use of antifibrinolytic drugs for treating primary PPH. OBJECTIVES To determine the effectiveness and safety of antifibrinolytic drugs for treating primary PPH. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (28 May 2017) and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials (RCTs), including cluster-randomised trials of antifibrinolytic drugs (aprotinin, TXA, epsilon-aminocaproic acid (EACA) and aminomethylbenzoic acid, administered by whatever route) for primary PPH in women.Participants in the trials were women after birth following a pregnancy of at least 24 weeks' gestation with a diagnosis of PPH, regardless of mode of birth (vaginal or caesarean section) or other aspects of third stage management.We have not included quasi-randomised trials, or cross-over studies. Studies reported as abstracts have not been included if there was insufficient information to allow assessment of risk of bias.In this review we only identified studies looking at TXA. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data from each study using an agreed form. We entered data into Review Manager software and checked for accuracy.For key review outcomes, we rated the quality of the evidence as 'high', 'moderate', 'low' or 'very low' according to the GRADE approach. MAIN RESULTS Three trials (20,412 women) met our inclusion criteria. Two trials (20,212 women) compared intravenous (IV) TXA with placebo or standard care and were conducted in acute hospital settings (labour ward, emergency department) (in high-, middle- and low-income countries).One other trial (involving 200 women) was conducted in Iran and compared IV TXA with rectal misoprostol, but did not report on any of this review's primary or GRADE outcomes. There were no trials that assessed EACA, aprotinin or aminomethylbenzoic acid.Standard care plus IV TXA for the treatment of primary PPH compared with placebo or standard care aloneTwo trials (20,212 women) assessed the effect of TXA for the treatment of primary PPH compared with placebo or standard care alone. The larger of these (The WOMAN trial) contributed over 99% of the data and was assessed as being at low risk of bias. The quality of the evidence varied for different outcomes, Overall, evidence was mainly graded as moderate to high quality.The data show that IV TXA reduces the risk of maternal death due to bleeding (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.65 to 1.00; two trials, 20,172 women; quality of evidence: moderate). The quality of evidence was rated as moderate due to imprecision of effect estimate. The effect was more evident in women given treatment between one and three hours after giving birth with no apparent reduction when given after three hours (< one hour = RR 0.80, 95% CI 0.55 to 1.16; one to three hours = RR 0.60, 95% CI 0.41 to 0.88; > three hours = RR 1.07, 95% 0.76 to 1.51; test for subgroup differences: Chi² = 4.90, df = 2 (P = 0.09), I² = 59.2%). There was no heterogeneity in the effect by mode of birth (test for subgroup differences: Chi² = 0.01, df = 1 (P = 0.91), I² = 0%). There were fewer deaths from all causes in women receiving TXA, although the 95% CI for the effect estimate crosses the line of no effect (RR 0.88, 95% CI 0.74 to 1.05; two trials, 20,172 women, quality of evidence: moderate). Results from one trial with 151 women suggest that blood loss of ≥ 500 mL after randomisation may be reduced (RR 0.50, 95% CI 0.27 to 0.93; one trial, 151 women; quality of evidence: low). TXA did not reduce the risk of serious maternal morbidity (RR 0.99, 95% CI 0.83 to 1.19; one trial, 20,015 women; quality of evidence: high), hysterectomy to control bleeding (RR 0.95, 95% CI 0.81 to 1.12; one trial, 20,017 women; quality of evidence: high) receipt of blood transfusion (any) (RR 1.00, 95% CI 0.97 to 1.03; two trials, 20,167 women; quality of evidence: moderate) or maternal vascular occlusive events (any), although results were imprecise for this latter outcome (RR 0.88, 95% CI 0.54 to 1.43; one trial, 20,018 women; quality of evidence: moderate). There was an increase in the use of brace sutures in the TXA group (RR 1.19, 95% CI 1.01, 1.41) and a reduction in the need for laparotomy for bleeding (RR 0.64, 95% CI 0.49, 0.85). AUTHORS' CONCLUSIONS TXA when administered intravenously reduces mortality due to bleeding in women with primary PPH, irrespective of mode of birth, and without increasing the risk of thromboembolic events. Taken together with the reliable evidence of the effect of TXA in trauma patients, the evidence suggests that TXA is effective if given as early as possible.Facilities for IV administration may not be available in non-hospital settings therefore, alternative routes to IV administration need to be investigated.
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Affiliation(s)
- Haleema Shakur
- London School of Hygiene & Tropical MedicineClinical Trials UnitKeppel StreetLondonUKWC1E 7HT
| | - Danielle Beaumont
- London School of Hygiene & Tropical MedicineClinical Trials UnitKeppel StreetLondonUKWC1E 7HT
| | - Sue Pavord
- Oxford University Hospitals, John Radcliffe HospitalClinical HaematologyOxfordUKOX3 9DU
| | - Angele Gayet‐Ageron
- London School of Hygiene & Tropical MedicineClinical Trials UnitKeppel StreetLondonUKWC1E 7HT
- University Hospitals of GenevaDivision of Clinical Epidemiology, Medical DirectorateGenevaSwitzerland
| | - Katharine Ker
- London School of Hygiene & Tropical MedicineClinical Trials UnitKeppel StreetLondonUKWC1E 7HT
| | - Hatem A Mousa
- Leicester Royal InfirmaryUniversity Department of Obstetrics and Gynaecology, Fetal and Maternal Medicine UnitInfirmary SquareLeicesterUKLE1 5WW
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