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Abad-Motos A, García-Erce JA, Gresele P, Páramo JA. Is tranexamic acid appropriate for all patients undergoing high-risk surgery? Curr Opin Crit Care 2024:00075198-990000000-00209. [PMID: 39248078 DOI: 10.1097/mcc.0000000000001207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024]
Abstract
PURPOSE OF REVIEW Tranexamic acid (TXA), an antifibrinolytic agent, reduces surgical bleeding in a variety of procedures, such as cardiac, orthopedic, abdominal, and urologic surgery, cesarean section, and neurosurgery. However, there are surgical interventions for which its use is not yet widespread, and some caution persists because of concerns regarding thrombotic risk. The purpose of this review is to analyze the most recent evidence in various subgroups of surgical specialties and the association of TXA with thrombotic events and other side effects (e.g. seizures). RECENT FINDINGS Recent clinical trials and meta-analyses have shown that the efficacy and safety vary according to the clinical context, timing of administration, and dose. Some reports found that TXA reduces major bleeding by 25% without a significant increase in thrombotic events. SUMMARY Wider use of TXA has the potential to improve surgical safety, avoid unnecessary blood use, and save healthcare funds.
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Affiliation(s)
- Ane Abad-Motos
- Anesthesia and Critical Care Department, Donostia University Hospital, Donostia-San Sebastián
- Patient Blood Management Working Group of the Spanish Society of Anesthesiology and Critical Care (SEDAR)
| | | | - Paolo Gresele
- Department of Medicine and Surgery, Perugia University, Perugia, Italy
| | - Jose A Páramo
- Hematology Department, University Clinic of Navarra, Pamplona, Spain
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Al Naimi A, Ma H, Pearl A, Yungtum G, Rangasamy V. Prophylactic tranexamic acid for reducing blood loss in pregnant females undergoing cesarean section: A systematic review and meta-analysis. J Obstet Gynaecol Res 2024; 50:1439-1458. [PMID: 39082365 DOI: 10.1111/jog.16036] [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: 05/28/2024] [Accepted: 07/15/2024] [Indexed: 10/10/2024]
Abstract
OBJECTIVE We aim to assess the efficacy of prophylactic tranexamic acid (TXA) in reducing blood loss after cesarean section (CS). METHODS We systematically searched PubMed and Embase for randomized controlled trials published between 1990 and 2023 to conduct a meta-analysis on adult women undergoing CS and receiving prophylactic TXA. RESULTS Twenty-four trials, comprising 19 584 participants, were included. Most studies included women with healthy, full-term, singleton pregnancies. The pooled estimate showed a reduction in mean blood loss in the TXA arm with a standardized mean difference (SMD) of -1.50 (-2.03, -0.98: p < 0.001). There was a high level of heterogeneity (I2 98.86%). A subgroup analysis demonstrated no statistical difference in the effect of TXA on blood loss at 2 h of follow-up with SMD of -2.24 (-3.23, -1.35) compared to -1.07 (-1.56, -0.58) and -1.10 (-2.62, -0.42) at 24 and 48 h, respectively (p = 0.11). The effect of TXA on blood loss was smaller in high-income countries with SMD -0.24 (-0.44, -0.04) (I2 63%) than in low-/middle-income countries -1.78 (-2.35, -1.21) with I2 98%. Only three studies had low risk of bias and the effect of TXA from two of them was SMD -0.31 (-0.54, -0.09) (I2 0%). CONCLUSIONS Despite the apparent beneficial effect of TXA in reducing blood loss after CS for women with uncomplicated term pregnancies, heterogeneity remains a serious concern. The current body of knowledge consists predominantly of small, likely biased studies, and large unbiased studies show only limited effects of prophylactic TXA.
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Affiliation(s)
- Ammar Al Naimi
- Department of Obstetrics and Gynecology, Buergerhospital, Frankfurt, Germany
- Department of Obstetrics and Perinatal Medicine, Goethe University Hospital of Frankfurt, Frankfurt, Germany
| | - Haobo Ma
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Abarna Pearl
- Department of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Greg Yungtum
- Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Valluvan Rangasamy
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Sinha N, Rajbhar S, Thakur P, Agrawal S, Singh V. Role of prophylactic tranexamic acid in reducing blood loss during cesarean section: A double-blind placebo-controlled randomized controlled trial. J Family Med Prim Care 2024; 13:1760-1765. [PMID: 38948612 PMCID: PMC11213430 DOI: 10.4103/jfmpc.jfmpc_1541_23] [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: 09/15/2023] [Revised: 12/04/2023] [Accepted: 12/08/2023] [Indexed: 07/02/2024] Open
Abstract
Background Postpartum hemorrhage (PPH) is defined by the World Health Organization as blood loss of ≥500 mL within 24 h of delivery. Globally, hemorrhage accounts for 27.1% of maternal deaths, making it the leading direct cause of maternal death. PPH has been identified in more than two-thirds of reported hemorrhage-related deaths, causing 38% of maternal deaths in India. Tranexamic acid, an antifibrinolytic, has been used to control bleeding after PPH is identified. Materials and Methods Antenatal women admitted for elective cesarean section were randomized into two arms: the case group (received one gram of tranexamic acid 20 min prior to skin incision) and the control group (received a placebo), each group consisting of 36 participants. Clinical Trials Registry - India (CTRI) registration number - CTRI/2021/02/031579. Results The mean (±standard deviation [SD]) intraoperative blood loss in the case group was 241.25 (±67.83) mL, and in the control group, it was 344.92 (±146.67) mL (P = 0.001), while postoperative blood loss did not differ significantly between the groups (P = 0.1470). In terms of the difference in hemoglobin, there was a significant difference between the two groups (P = 0.001). No significant maternal or neonatal side effects were found. Conclusion Preoperative tranexamic acid, when given in elective cesarean section, significantly reduces intraoperative blood loss.
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Affiliation(s)
- Nutan Sinha
- Department of Obstetrics and Gynecology, AIIMS RAIPUR, Raipur, Chattisgarh, India
| | - Sarita Rajbhar
- Department of Obstetrics and Gynecology, AIIMS RAIPUR, Raipur, Chattisgarh, India
| | - Pushpawati Thakur
- Department of Obstetrics and Gynecology, AIIMS RAIPUR, Raipur, Chattisgarh, India
| | - Sarita Agrawal
- Department of Obstetrics and Gynecology, AIIMS RAIPUR, Raipur, Chattisgarh, India
| | - Vinita Singh
- Department of Obstetrics and Gynecology, AIIMS RAIPUR, Raipur, Chattisgarh, India
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Mackeen AD, Sullivan MV, Berghella V. Evidence-based cesarean delivery: preoperative management (part 7). Am J Obstet Gynecol MFM 2024; 6:101362. [PMID: 38574855 DOI: 10.1016/j.ajogmf.2024.101362] [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: 01/19/2024] [Revised: 03/18/2024] [Accepted: 03/28/2024] [Indexed: 04/06/2024]
Abstract
Preoperative preparation for cesarean delivery is a multistep approach for which protocols should exist at each hospital system. These protocols should be guided by the findings of this review. The interventions reviewed and recommendations made for this review have a common goal of decreasing maternal and neonatal morbidity and mortality related to cesarean delivery. The preoperative period starts before the patient's arrival to the hospital and ends immediately before skin incision. The Centers for Disease Control and Prevention recommends showering with either soap or an antiseptic solution at least the night before a procedure. Skin cleansing in addition to this has not been shown to further decrease rates of infection. Hair removal at the cesarean skin incision site is not necessary, but if preferred by the surgical team then clipping or depilatory creams should be used rather than shaving. Preoperative enema is not recommended. A clear liquid diet may be ingested up to 2 hours before and a light meal up to 6 hours before cesarean delivery. Consider giving a preoperative carbohydrate drink to nondiabetic patients up to 2 hours before planned cesarean delivery. Weight-based intravenous cefazolin is recommended 60 minutes before skin incision: 1-2 g intravenous for patients without obesity and 2 g for patients with obesity or weight ≥80 kg. Adjunctive azithromycin 500 mg intravenous is recommended for patients with labor or rupture of membranes. Preoperative gabapentin can be considered as a way to decrease pain scores with movement in the postoperative period. Tranexamic acid (1 g in 10-20 mL of saline or 10 mg/kg intravenous) is recommended prophylactically for patients at high risk of postpartum hemorrhage and can be considered in all patients. Routine use of mechanical venous thromboembolism prophylaxis is recommended preoperatively and is to be continued until the patient is ambulatory. Music and active warming of the patient, and adequate operating room temperature improves outcomes for the patient and neonate, respectively. Noise levels should allow clear communication between teams; however, a specific decibel level has not been defined in the data. Patient positioning with left lateral tilt decreases hypotensive episodes compared with right lateral tilt, which is not recommended. Manual displacers result in fewer hypotensive episodes than left lateral tilt. Both vaginal and skin preparation should be performed with either chlorhexidine (preferred) or povidone iodine. Placement of an indwelling urinary catheter is not necessary. Nonadhesive drapes are recommended. Cell salvage, although effective for high-risk patients, is not recommended for routine use. Maternal supplemental oxygen does not improve outcomes. A surgical safety checklist (including a timeout) is recommended for all cesarean deliveries.
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Affiliation(s)
- A Dhanya Mackeen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Geisinger, Danville, PA (Drs Mackeen and Sullivan).
| | - Maranda V Sullivan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Geisinger, Danville, PA (Drs Mackeen and Sullivan)
| | - Vincenzo Berghella
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA (Dr Berghella)
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Kowalczyk JJ, Cecconi M, Butwick AJ. Evaluating tranexamic acid for the prevention and treatment of obstetric hemorrhage. Curr Opin Obstet Gynecol 2024; 36:88-96. [PMID: 38170626 DOI: 10.1097/gco.0000000000000935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
PURPOSE OF REVIEW Tranexamic acid (TXA) has emerged as a promising pharmacological adjunct to treat and prevent postpartum hemorrhage (PPH). We provide an overview of TXA, including its pharmacology, key findings of randomized trials and observational studies, and critical patient safety information. RECENT FINDINGS Pharmacokinetic data indicate that TXA infusions result in peak plasma concentration within 3 min (range: 1-6.6 min). Ex-vivo pharmacodynamic data suggest that low-dose TXA (5 mg/kg) inhibits maximum lysis for at least 1 h. In predominantly developing countries, TXA has demonstrated a 19% reduction in the risk of bleeding-related death among patients with PPH. Based on high-quality randomized trials, TXA prophylaxis does not effectively reduce the risk of PPH during vaginal delivery and is likely ineffective in reducing the PPH risk during cesarean delivery. TXA exposure does not increase the risk of maternal thrombotic events. Maternal deaths have occurred from accidental intrathecal TXA injection from look-alike medication errors. SUMMARY TXA has shown promise as an important adjunct for PPH treatment, especially in low-resource settings. However, TXA is not recommended as PPH prophylaxis during vaginal or cesarean delivery. Patient safety initiatives should be prioritized to prevent maternal death from accidental intrathecal TXA injection.
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Affiliation(s)
- John J Kowalczyk
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maurizio Cecconi
- Biomedical Sciences Department, Humanitas University
- Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Alexander J Butwick
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
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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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Acharya P, Amin A, Nallamotu S, Riaz CZ, Kuruba V, Senthilkumar V, Kune H, Bhatti SS, Sarlat IM, Krishna CV, Asif K, Nashwan AJ, Cheema HA. Prehospital tranexamic acid in trauma patients: a systematic review and meta-analysis of randomized controlled trials. Front Med (Lausanne) 2023; 10:1284016. [PMID: 37928456 PMCID: PMC10623347 DOI: 10.3389/fmed.2023.1284016] [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] [Received: 08/28/2023] [Accepted: 10/06/2023] [Indexed: 11/07/2023] Open
Abstract
Background Prehospital tranexamic acid (TXA) may hold substantial benefits for trauma patients; however, the data underlying its efficacy and safety is scarce. Methods We searched PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov from inception to July 2023 for all randomized controlled trials (RCTs) investigating prehospital TXA in trauma patients as compared to placebo or standard care without TXA. Data were pooled under a random-effects model using RevMan 5.4 with risk ratio (RR) and mean difference (MD) as the effect measures. Results A total of three RCTs were included in this review. Regarding the primary outcomes, prehospital TXA reduced the risk of 1-month mortality (RR 0.82, 95% CI 0.69-0.97) but did not increase survival with a favorable functional outcome at 6 months (RR 1.00, 95% CI 0.93-1.09). Prehospital TXA also reduced the risk of 24-h mortality but did not affect the risk of mortality due to bleeding and traumatic brain injury. There was no significant difference between the TXA and control groups in the incidence of RBC transfusion, and the number of ventilator- and ICU-free days. Prehospital TXA did not increase the risk of adverse events except for a small increase in the incidence of infections. Conclusion Prehospital TXA is useful in reducing mortality in trauma patients without a notable increase in the risk of adverse events. However, there was no effect on the 6-month favorable functional status. Further large-scale trials are required to validate the aforementioned findings. Systematic review registration PROSPERO (CRD42023451759).
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Affiliation(s)
- Pawan Acharya
- Department of Trauma and Orthopedics, Lister Hospital, Stevenage, United Kingdom
| | - Aamir Amin
- Department of Cardiothoracic Surgery, Royal Brompton Hospital, London, United Kingdom
| | | | | | - Venkataramana Kuruba
- Department of Orthopedics, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, India
| | | | - Harika Kune
- Kamineni Institute of Medical Sciences, Narketpally, Telangana, India
| | | | - Iván Moguel Sarlat
- Servicio de Ortopedia y Traumatología, Hospital General Dr Agustín O’Horán, Mérida, Yucatán, Mexico
| | | | - Kainat Asif
- Department of Medicine, Dr. Ruth K. M. Pfau Civil Hospital Karachi, Karachi, Pakistan
| | | | - Huzaifa Ahmad Cheema
- Department of Emergency Medicine, King Edward Medical University, Lahore, Pakistan
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Ker K, Shakur-Still H, Sentilhes L, Pacheco LD, Saade G, Deneux-Tharaux C, Brenner A, Mansukhani R, Ageron FX, Prowse D, Chaudhri R, Olayemi O, Roberts I. Tranexamic acid for the prevention of postpartum bleeding: Protocol for a systematic review and individual patient data meta-analysis. Gates Open Res 2023; 7:3. [PMID: 37601311 PMCID: PMC10439279 DOI: 10.12688/gatesopenres.13747.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 09/05/2023] Open
Abstract
Tranexamic acid (TXA) reduces the risk of death and is recommended as a treatment for women with severe postpartum bleeding. There is hope that giving TXA shortly before or immediately after birth could prevent postpartum bleeding. Extending the use of TXA to prevent harmful postpartum bleeding could improve outcomes for millions of women; however we must carefully consider the balance of benefits and potential harms. This article describes the protocol for a systematic review and individual patient data (IPD) meta-analysis to assess the effectiveness and safety of TXA for preventing postpartum bleeding in all women giving birth, and to explore how the effects vary by underlying risk and other patient characteristics. Methods: We will search for prospectively registered, randomised controlled trials involving 500 patients or more assessing the effects of TXA in women giving birth. Two authors will extract data and assess risk of bias. IPD data will be sought from eligible trials. Primary outcomes will be life-threatening bleeding and thromboembolic events. We will use a one-stage model to analyse the data. Subgroup analyses will be conducted to explore whether the effectiveness and safety of TXA varies by underlying risk, type birth, maternal haemoglobin (Hb), and timing of TXA. This protocol is registered on PROSPERO (CRD42022345775). Conclusions: This systematic review and IPD meta-analysis will address important clinical questions about the effectiveness and safety of the use of TXA for the prevention of postpartum bleeding that cannot be answered reliably using aggregate data and will inform the decision of who to treat. PROSPERO registration: CRD42022345775 Keywords Anti-fibrinolytics; Tranexamic acid; childbirth; postpartum haemorrhage; meta-analysis.
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Affiliation(s)
- The Anti-fibrinolytics Trialists Collaborators – Obstetric Trialists Group
- CTU Global Health Trials Group, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
- Department of Obstetrics & Gynecology, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia, USA
- INSERM U1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology & Statistics Sorbonne Paris Cité, Paris Descartes University, Paris, France
- Department of Emergency Medicine, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
- Rawalpindi Medical College, Rawalpindi, Pakistan
- University of Ibadan College of Medicine, Ibadan, Nigeria
| | - Katharine Ker
- CTU Global Health Trials Group, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Haleema Shakur-Still
- CTU Global Health Trials Group, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Loïc Sentilhes
- Department of Obstetrics & Gynecology, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - Luis D. Pacheco
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - George Saade
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Catherine Deneux-Tharaux
- INSERM U1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology & Statistics Sorbonne Paris Cité, Paris Descartes University, Paris, France
| | - Amy Brenner
- CTU Global Health Trials Group, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Raoul Mansukhani
- CTU Global Health Trials Group, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - François-Xavier Ageron
- Department of Emergency Medicine, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Danielle Prowse
- CTU Global Health Trials Group, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | | | | | - Ian Roberts
- CTU Global Health Trials Group, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
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