Comparison of the Effect of Intravenous Tranexamic Acid and Sublingual Misoprostol on Reducing Bleeding After Cesarean Section: A Double-Blind Randomized Clinical Trial

Tranexamic acid versus misoprostol for management of postpartum hemorrhage: A systematic review and meta-analysis of randomized controlled trials

AIM

To conduct the first-ever systematic review and meta-analysis of randomized controlled trials (RCTs) on the antihemorrhagic utility and safety of tranexamic acid (TXA) versus misoprostol for management (prevention and/or treatment) of postpartum hemorrhage (PPH).

METHODS

Six databases were screened from inception until May 2023 and updated in September 2023. The RCTs were assessed for quality according to the Cochrane's risk of bias tool. The endpoints were summarized as mean difference (MD) or risk ratio (RR) with 95% confidence interval (CI) in a random-effects model.

RESULTS

Ten RCTs with 2121 patients (TXA = 1061 and misoprostol = 1060) were analyzed. There was no significant difference between TXA and misoprostol groups regarding the mean intraoperative blood loss (n = 9 RCTs, MD = 17.32 ml, 95% CI [-40.43, 75.07], p = 0.56), mean change in hemoglobin (n = 6 RCTs, MD = 0.11 mg/dl, 95% CI [-0.1, 0.31], p = 0.30), mean hospital stay (n = 2 RCTs, MD = -0.3 day, 95% CI [-0.61, 0.01], p = 0.06), blood transfusion rate (n = 4 RCTs, RR = 0.49, 95% CI [0.16, 1.47], p = 0.2), and rate of additional uterotonic agents (n = 4 RCTs, RR = 1.05, 95% CI [0.72, 1.53], p = 0.81). Leave-one-out sensitivity analysis showed robustness of the results, and there was no evidence of publication bias. Regarding safety endpoints, there was no significant difference between both groups regarding the rates of minor side effects, such as diarrhea, fever, nausea, and vomiting. No patient developed thromboembolic events in the TXA group.

CONCLUSION

There was no significant antihemorrhagic efficacy between adjunct TXA and misoprostol for the management of PPH. The safety profile was comparable between both agents.

WITHDRAWN: The Effect of Preoperative Intravenous Tranexamic Acid Versus Rectal Misoprostol in Reducing Blood Loss During and After Elective Cesarean Delivery in Primigravida: A Double-Blinded, Randomized, Comparative-Placebo Trial

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Tranexamic acid for the prevention of blood loss after cesarean section: an updated systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Tranexamic acid is a cost-effective intervention for the prevention of postpartum hemorrhage among women who undergo cesarean delivery, but the evidence to support its use is conflicting. We conducted this meta-analysis to evaluate the efficacy and safety of tranexamic acid in low- and high-risk cesarean deliveries.

DATA SOURCES

We searched MEDLINE (via PubMed), Embase, the Cochrane Library, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform portal from inception to April 2022 (updated October 2022 and February 2023) with no language restrictions. In addition, grey literature sources were also explored.

STUDY ELIGIBILITY CRITERIA

All randomized controlled trials that investigated the prophylactic use of intravenous tranexamic acid in addition to standard uterotonic agents among women who underwent cesarean deliveries in comparison with a placebo, standard treatment, or prostaglandins were included in this meta-analysis.

METHODS

We used the revised Cochrane Risk of Bias tool (RoB 2.0) to assess the quality of the included randomized controlled trials. RevMan 5.4 was used to conduct all statistical analyses using a random-effects model.

RESULTS

We included 50 randomized controlled trials (6 in only high-risk patients and 2 with prostaglandins as the comparator) that evaluated tranexamic acid in our meta-analysis. Tranexamic acid reduced the risk for blood loss >1000 mL, the mean total blood loss, and the need for blood transfusion in both low- and high-risk patients. Tranexamic acid was associated with a beneficial effect in the secondary outcomes, including a decline in hemoglobin levels and the need for additional uterotonic agents. Tranexamic acid increased the risk for nonthromboembolic adverse events but, based on limited data, did not increase the incidence of thromboembolic events. The administration of tranexamic acid before skin incision, but not after cord clamping, was associated with a large benefit. The quality of evidence was rated as low to very low for outcomes in the low-risk population and moderate for most outcomes in the high-risk subgroup.

CONCLUSION

Tranexamic acid may reduce the risk for blood loss in cesarean deliveries with a higher benefit observed in high-risk patients, but the lack of high-quality evidence precludes any strong conclusions. The administration of tranexamic acid before skin incision, but not after cord clamping, was associated with a large benefit. Additional studies, especially in the high-risk population and focused on evaluating the timing of tranexamic acid administration, are needed to confirm or refute these findings.

Tranexamic acid for the prevention of postpartum hemorrhage in women undergoing cesarean delivery: an updated meta-analysis

OBJECTIVE

This study aimed to assess the efficacy and safety of prophylactic tranexamic acid administration vs standard uterotonic agents alone among women undergoing cesarean delivery.

DATA SOURCES

MEDLINE, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and Google Scholar were systematically searched from inception to June 30, 2021.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials comparing intravenous tranexamic acid administration with placebo in women undergoing cesarean delivery and receiving standard prophylactic uterotonic agents were held eligible.

STUDY APPRAISAL AND SYNTHESIS METHODS

The risk of bias of individual studies was appraised with the Risk of Bias 2 tool. Meta-analysis was conducted by fitting random-effects models using restricted maximum likelihood. Subgroup analysis was performed on the basis of country, protocol availability, double-blinding, risk of bias, sample size, and tranexamic acid dose. A 1-stage meta-analysis was performed as a sensitivity analysis. The credibility of outcomes was appraised with the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

Overall, 36 studies with 10,659 women were included. Tranexamic acid administration was associated with significantly lower total blood loss (mean difference, -189.44 mL; 95% confidence intervals, -218.63 to -160.25), lower hemoglobin drop (mean difference, 8.22%; 95% confidence interval, 5.54-10.90), decreased risk of blood loss of >1000 mL (odds ratio, 0.37; 95% confidence interval, 0.22-0.60), transfusion requirement (odds ratio, 0.41; 95% confidence interval, 0.26-0.65), and need of additional uterotonics (odds ratio, 0.36; 95% confidence interval, 0.25-0.52). Subgroup analysis indicated a greater effect of tranexamic acid on total blood loss reduction in low-middle income countries. The outcomes remained stable by separately evaluating women at low bleeding risk. The 1-stage meta-analysis demonstrated similar outcomes with the primary analysis. The quality of evidence was judged to be moderate regarding total blood loss and hemoglobin percentage change and low for the other outcomes.

CONCLUSION

This meta-analysis suggested that prophylactic tranexamic acid administration is effective among women undergoing cesarean delivery in lowering postpartum blood loss and limiting hemoglobin drop. Further research is needed to test its efficacy in high-risk populations and verify its safety profile.

Rectal vs. sublingual misoprostol in cesarean section: Three‑arm, randomized clinical trial

BACKGROUND

Misoprostol is a myometrial stimulant with uterotonic properties and can be administered rectally, vaginally, or sublingually. Numerous studies have investigated the effect of misoprostol on the prevention and treatment of PPH (postpartum hemorrhage) after vaginal delivery, but its use to control PPH during cesarean section has not been widely studied.

METHODS

In this clinical trial study, 180 pregnant women who were candidates for cesarean section were included in the study. They were divided into 3 groups of 60 people (sublingual misoprostol group, rectal misoprostol group, control group). In all three groups, the volume of blood lost was recorded in the checklist at the end of surgery. Data were entered into SPSS software and analyzed.

RESULTS

The mean bleeding in the control group was 225.4±63.9, while it was 137.9±33.8 and 118.9±28.5 in the sublingual misoprostol group and rectal misoprostol group, respectively. We had significantly more bleeding in the control group (p<0.001) compared to the other two groups.

CONCLUSION

These results confirm the positive effect of misoprostol in reducing bleeding and show the superiority of using rectal misoprostol compared to other methods of reducing bleeding during cesarean section.