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Provinciatto H, Barbalho ME, da Câmara PM, Donadon IB, Fonseca LM, Bertani MS, Marinho AD, Sirena E, Provinciatto A, Amaral S. Prophylactic tranexamic acid in Cesarean delivery: an updated meta-analysis with a trial sequential analysis. Can J Anaesth 2024; 71:465-478. [PMID: 38453797 DOI: 10.1007/s12630-024-02715-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 10/29/2023] [Accepted: 11/04/2023] [Indexed: 03/09/2024] Open
Abstract
PURPOSE Postpartum hemorrhage (PPH) is a leading cause of maternal mortality worldwide. Although several studies on the prophylactic use of tranexamic acid (TXA) in parturients undergoing Cesarean delivery have been published, conflicting results raise questions regarding its use. Thus, we aimed to investigate the safety and efficacy of PPH prophylaxis with TXA. SOURCE We searched PubMed®, Embase, Cochrane Central, and ClinicalTrials.gov for randomized controlled trials (RCTs) comparing prophylactic TXA with placebo or no treatment in parturients undergoing Cesarean delivery. Our main outcomes were PPH, any blood transfusion, need for additional uterotonics, and adverse events. We performed a trial sequential analysis (TSA) of all outcomes to investigate the reliability and conclusiveness of findings. PRINCIPAL FINDINGS We included 38 RCTs including 22,940 parturients, 11,535 (50%) of whom were randomized to receive prophylactic TXA. Patients treated with TXA had significantly fewer cases of PPH (risk ratio [RR], 0.51; 95% confidence interval [CI], 0.38 to 0.69; P < 0.001); less blood transfusion (RR, 0.43; 95% CI, 0.30 to 0.61; P < 0.001), and less use of additional uterotonics (RR, 0.52; 95% CI, 0.40 to 0.68; P < 0.001). No significant differences were found between the groups in terms of adverse effects and thromboembolic events. CONCLUSION Prophylactic TXA administration for parturients undergoing Cesarean delivery significantly reduced blood loss, without increasing adverse events, supporting its use as a safe and effective strategy for reducing PPH in this population. STUDY REGISTRATION PROSPERO (CRD42023422188); first submitted 27 April 2023.
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Affiliation(s)
- Henrique Provinciatto
- Barao de Maua University Center, Avenida Portugal, 2433, Ribeirao Preto, SP, Brazil.
| | | | | | | | - Luiza M Fonseca
- Faculty of Medical Sciences of Minas Gerais, Belo Horizonte, Brazil
| | | | - Alice D Marinho
- Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | - Sara Amaral
- Regional Hospital Deputado Afonso Guizzo, Araranguá, Brazil
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Ortuanya KE, Eleje GU, Ezugwu FO, Odugu BU, Ikechebelu JI, Ugwu EO, Eke AC, Awkadigwe FI, Ezenwaeze MN, Ofor IJ, Okafor CC, Okafor CG. Prophylactic tranexamic acid for reducing intraoperative blood loss during cesarean section in women at high risk of postpartum hemorrhage: A double-blind placebo randomized controlled trial. WOMEN'S HEALTH (LONDON, ENGLAND) 2024; 20:17455057231225311. [PMID: 38279808 PMCID: PMC10822094 DOI: 10.1177/17455057231225311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 10/16/2023] [Accepted: 12/20/2023] [Indexed: 01/29/2024]
Abstract
BACKGROUND Postpartum hemorrhage remains a leading cause of maternal mortality especially in developing countries. The majority of previous trials on the effectiveness of tranexamic acid in reducing blood loss were performed in low-risk women for postpartum hemorrhage. A recent Cochrane Systematic Review recommended that further research was needed to determine the effects of prophylactic tranexamic acid for preventing intraoperative blood loss in women at high risk of postpartum hemorrhage. OBJECTIVE This study aimed to evaluate the effectiveness and safety of tranexamic acid in reducing intraoperative blood loss when given prior to cesarean delivery in women at high risk of postpartum hemorrhage. STUDY DESIGN The study is a double-blind randomized controlled trial. METHODS The study consisted of 200 term pregnant women and high-risk preterm pregnancies scheduled for lower-segment cesarean delivery at Enugu State University of Science and Technology, Teaching Hospital, Parklane, Enugu, Nigeria. The participants were randomized into two arms (intravenous 1 g of tranexamic acid or placebo) in a ratio of 1:1. The participants received either 1 g of tranexamic acid or placebo (20 mL of normal saline) intravenously at least 10 min prior to commencement of the surgery. The primary outcome measures were the mean intraoperative blood loss and hematocrit change 48 h postoperatively. RESULTS The baseline sociodemographic characteristics were similar in both groups. The tranexamic acid group when compared to the placebo group showed significantly lower mean blood loss (442.94 ± 200.97 versus 801.28 ± 258.68 mL; p = 0.001), higher mean postoperative hemoglobin (10.39 + 0.96 versus 9.67 ± 0.86 g/dL; p = 0.001), lower incidence of postpartum hemorrhage (1.0% versus 19.0%; p = 0.001), and lower need for use of additional uterotonic agents after routine management of the third stage of labor (39.0% versus 68.0%; p = 0.001), respectively. However, there was no significant difference in the mean preoperative hemoglobin (11.24 ± 0.88 versus 11.15 ± 0.90 g/dL; p = 0.457), need for other surgical intervention for postpartum hemorrhage (p > 0.05), and reported side effect, respectively, between the two groups. CONCLUSION Prophylactic administration of tranexamic acid significantly decreases postpartum blood loss, improves postpartum hemoglobin, decreases the need for additional uterotonics, and prevents postpartum hemorrhage following cesarean section in pregnant women at high risk of postpartum hemorrhage. Its routine use during cesarean section in high-risk women may be encouraged.The trial was registered in the Pan-African Clinical Trial Registry with approval number PACTR202107872851363.
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Affiliation(s)
- Kelvin E Ortuanya
- Department of Obstetrics & Gynaecology, Enugu State University of Science and Technology Teaching Hospital Parklane, Enugu, Nigeria
| | - George U Eleje
- Department of Obstetrics & Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
| | - Frank O Ezugwu
- Department of Obstetrics & Gynaecology, Enugu State University of Science and Technology Teaching Hospital Parklane, Enugu, Nigeria
| | - Boniface U Odugu
- Department of Obstetrics & Gynaecology, Enugu State University of Science and Technology Teaching Hospital Parklane, Enugu, Nigeria
| | - Joseph I Ikechebelu
- Department of Obstetrics & Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
| | - Emmanuel O Ugwu
- Department of Obstetrics and Gynaecology, College of Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Ahizechukwu C Eke
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fredrick I Awkadigwe
- Department of Obstetrics & Gynaecology, Enugu State University of Science and Technology Teaching Hospital Parklane, Enugu, Nigeria
| | - Malachy N Ezenwaeze
- Department of Obstetrics & Gynaecology, Enugu State University of Science and Technology Teaching Hospital Parklane, Enugu, Nigeria
| | - Ifeanyichukwu J Ofor
- Department of Obstetrics & Gynaecology, Enugu State University of Science and Technology Teaching Hospital Parklane, Enugu, Nigeria
| | - Chidinma C Okafor
- Department of Psychiatry, Leicestershire Partnership NHS Trust, Leicester, UK
| | - Chigozie G Okafor
- Department of Obstetrics & Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
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Cheema HA, Ahmad AB, Ehsan M, Shahid A, Ayyan M, Azeem S, Hussain A, Shahid A, Nashwan AJ, Mikuš M, Laganà AS. Tranexamic acid for the prevention of blood loss after cesarean section: an updated systematic review and meta-analysis of randomized controlled trials. Am J Obstet Gynecol MFM 2023; 5:101049. [PMID: 37311484 DOI: 10.1016/j.ajogmf.2023.101049] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/01/2023] [Accepted: 06/06/2023] [Indexed: 06/15/2023]
Abstract
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.
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Affiliation(s)
- Huzaifa Ahmad Cheema
- Department of Obstetrics and Gynaecology, King Edward Medical University, Lahore, Pakistan (Drs Cheema, Ahmad, Ehsan, Ab. Shahid, Ayyan, and Hussain); Department of Medicine, King Edward Medical University, Lahore, Pakistan (Drs Cheema, Ahmad, and Azeem)
| | - Aamna Badar Ahmad
- Department of Obstetrics and Gynaecology, King Edward Medical University, Lahore, Pakistan (Drs Cheema, Ahmad, Ehsan, Ab. Shahid, Ayyan, and Hussain); Department of Medicine, King Edward Medical University, Lahore, Pakistan (Drs Cheema, Ahmad, and Azeem)
| | - Muhammad Ehsan
- Department of Obstetrics and Gynaecology, King Edward Medical University, Lahore, Pakistan (Drs Cheema, Ahmad, Ehsan, Ab. Shahid, Ayyan, and Hussain)
| | - Abia Shahid
- Department of Obstetrics and Gynaecology, King Edward Medical University, Lahore, Pakistan (Drs Cheema, Ahmad, Ehsan, Ab. Shahid, Ayyan, and Hussain)
| | - Muhammad Ayyan
- Department of Obstetrics and Gynaecology, King Edward Medical University, Lahore, Pakistan (Drs Cheema, Ahmad, Ehsan, Ab. Shahid, Ayyan, and Hussain)
| | - Saleha Azeem
- Department of Medicine, King Edward Medical University, Lahore, Pakistan (Drs Cheema, Ahmad, and Azeem)
| | - Ayesha Hussain
- Department of Obstetrics and Gynaecology, King Edward Medical University, Lahore, Pakistan (Drs Cheema, Ahmad, Ehsan, Ab. Shahid, Ayyan, and Hussain)
| | - Aden Shahid
- Department of Medicine, CMH Lahore Medical College and Institute of Dentistry, Lahore, Pakistan (Dr Ad. Shahid)
| | | | - Mislav Mikuš
- Department of Obstetrics and Gynecology, Clinical Hospital Center Zagreb, Zagreb, Croatia (Dr Mikuš)
| | - Antonio Simone Laganà
- Unit of Gynecologic Oncology, ARNAS "Civico - Di Cristina - Benfratelli," Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy (Dr Laganà)
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