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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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Neumann BG, Metgud MC, Hoffman MK, Patil K, Savanur M, Hanji V, Ganachari MS, Somannavar M, Goudar SS. Tranexamic acid to reduce blood loss in women at high risk of postpartum hemorrhage undergoing cesarean delivery-a randomized controlled trial. AJOG GLOBAL REPORTS 2024; 4:100316. [PMID: 38390367 PMCID: PMC10881416 DOI: 10.1016/j.xagr.2024.100316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Postpartum hemorrhage is a leading cause of maternal morbidity and mortality. Tranexamic acid has proven to be useful in treating hemorrhage from acute blood loss. However, its role in preventing blood loss in women at high risk of postpartum hemorrhage undergoing cesarean delivery is not well studied. OBJECTIVE This study aimed to assess the role of tranexamic acid in reducing blood loss during elective and unscheduled cesarean deliveries in women at high risk of postpartum hemorrhage. STUDY DESIGN This was a prospective, placebo-controlled, randomized controlled trial from March 2021 to February 2022 at the Karnatak Lingayat Education Society Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, India. Women at a high risk of postpartum hemorrhage undergoing cesarean delivery were recruited and randomized to receive either tranexamic acid or placebo (1:1) at least 10 minutes before skin incision. High-risk factors for postpartum hemorrhage included obesity, hypertension, multiparity, previous cesarean delivery, multiple pregnancy, abnormally implanted placenta, placenta previa, abruption, uterine leiomyomas, polyhydramnios, and fetal macrosomia. The primary outcome was blood loss, calculated by a formula using pre- and postoperative hematocrit levels. In addition, gravimetrically measured blood loss was measured and compared between the 2 groups. RESULTS A total of 212 women met the inclusion criteria and were randomized (tranexamic acid [n=106] and placebo [n=106]). The mean blood loss estimates were 400.9 mL in the tranexamic acid group and 597.9 mL in the placebo group (P<.001). The mean gravimetrically measured blood loss estimates were 379.2 mL in the tranexamic acid group and 431.1 mL in the placebo group (P<.001). In addition, there was a significant difference in the fall in hemoglobin levels (1.04 vs 1.61 g/dL) and change in hematocrit levels (3.20% vs 4.95%) from the pre- to postoperative period between the 2 groups (P<.001). No difference in the need for additional uterotonics (P=.26) or the need for postoperative parental iron (P=.18) was noted. No woman was transfused in either group. CONCLUSION High-risk women receiving tranexamic acid had significantly less blood loss than women receiving placebo during cesarean delivery.
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Affiliation(s)
- Bethany G Neumann
- OB Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Karnatak Lingayat Education Academy of Higher Education and Research, Belagavi, Karnataka, India (Drs Neumann, Metgud, Patil, Savanur and Hanji)
| | - Mrityunjay C Metgud
- OB Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Karnatak Lingayat Education Academy of Higher Education and Research, Belagavi, Karnataka, India (Drs Neumann, Metgud, Patil, Savanur and Hanji)
| | - Matthew K Hoffman
- Department of Obstetrics and Gynecology, ChristianaCare, Newark, DE (Dr Hoffman)
| | - Kamal Patil
- OB Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Karnatak Lingayat Education Academy of Higher Education and Research, Belagavi, Karnataka, India (Drs Neumann, Metgud, Patil, Savanur and Hanji)
| | - Mahadevi Savanur
- OB Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Karnatak Lingayat Education Academy of Higher Education and Research, Belagavi, Karnataka, India (Drs Neumann, Metgud, Patil, Savanur and Hanji)
| | - Vinutha Hanji
- OB Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Karnatak Lingayat Education Academy of Higher Education and Research, Belagavi, Karnataka, India (Drs Neumann, Metgud, Patil, Savanur and Hanji)
| | - Madiwalayya S Ganachari
- Department of Pharmacy Practice, Karnatak Lingayat Education College of Pharmacy, Karnatak Lingayat Education Academy of Higher Education and Research, Belagavi, Karnataka, India (Dr Ganachari)
| | - Manjunath Somannavar
- Department of Biochemistry, Jawaharlal Nehru Medical College, Karnatak Lingayat Education Academy of Higher Education and Research, Belagavi, Karnataka, India (Dr Somannavar)
| | - Shivaprasad S Goudar
- Women's and Children's Health Research Unit, Jawaharlal Nehru Medical College, Karnatak Lingayat Education Academy of Higher Education and Research, Belagavi, Karnataka, India (Dr Goudar)
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Al-Dardery NM, Abdelwahab OA, Abouzid M, Albakri K, Elkhadragy A, Katamesh BE, Hamamreh R, Mohd AB, Abdelaziz A, Khaity A. Efficacy and safety of tranexamic acid in prevention of postpartum hemorrhage: a systematic review and meta-analysis of 18,649 patients. BMC Pregnancy Childbirth 2023; 23:817. [PMID: 38001439 PMCID: PMC10668444 DOI: 10.1186/s12884-023-06100-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 11/01/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND In this meta-analysis, we aimed to update the clinical evidence regarding the efficacy and safety of TXA in the prevention of PPH. METHODS A literature search of PubMed, Scopus, Web of Science, Google Scholar, and Cochrane Library from inception until December 2022 was conducted. We included randomized controlled trials (RCTs) comparing TXA with a placebo among pregnant women. All relevant outcomes, such as total blood loss, the occurrence of nausea and/or vomiting, and changes in hemoglobin, were combined as odds ratios (OR) or mean differences (MD) in the meta-analysis models using STATA 17 MP. RESULTS We included 59 RCTs (18,649 patients) in this meta-analysis. For cesarean birth, TXA was favored over the placebo in reducing total blood loss (MD= -2.11 mL, 95%CI [-3.09 to -1.14], P < 0.001), and occurrence of nausea or/and vomiting (OR = 1.36, 95%CI [1.07 to 1.74], P = 0.01). For vaginal birth, the prophylactic use of TXA was associated with lower total blood loss, and higher occurrence of nausea and/or vomiting (MD= -0.89 mL, 95%CI [-1.47 to -0.31], OR = 2.36, 95%CI [1.32 to 4.21], P = 0.02), respectively. However, there were no differences between the groups in changes in hemoglobin during vaginal birth (MD = 0.20 g/dl, 95%CI [-0.07 to 0.48], P = 0.15). The overall risk of bias among the included studies varies from low to high risk of bias using ROB-II tool for RCTs. CONCLUSIONS This meta-analysis suggested that TXA administration is effective among women undergoing cesarean birth or vaginal birth in lowering total blood loss and limiting the occurrence of PPH. Further clinical trials are recommended to test its efficacy on high-risk populations.
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Affiliation(s)
- Nada Mostafa Al-Dardery
- Faculty of Medicine, Fayoum University, Fayoum, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Omar Ahmed Abdelwahab
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohamed Abouzid
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznan, Poland
- Doctoral School, Poznan University of Medical Sciences, Poznan, Poland
| | - Khaled Albakri
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Ali Elkhadragy
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | - Rawan Hamamreh
- Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Ahmed B Mohd
- Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Ahmed Abdelaziz
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Abdulrhman Khaity
- Medical Research Group of Egypt (MRGE), Cairo, Egypt.
- Faculty of Medicine, Elrazi University, Khartoum, 11115, Sudan.
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Binyamin Y, Frenkel A, Gruzman I, Lerman S, Bichovsky Y, Zlotnik A, Stav MY, Erez O, Orbach-Zinger S. Prophylactic Administration of Tranexamic Acid Reduces Blood Products' Transfusion and Intensive Care Admission in Women Undergoing High-Risk Cesarean Sections. J Clin Med 2023; 12:5253. [PMID: 37629295 PMCID: PMC10455366 DOI: 10.3390/jcm12165253] [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: 07/10/2023] [Revised: 08/07/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
Postpartum hemorrhage (PPH) remains a major cause of maternal mortality. Tranexamic acid (TxA) has shown effectiveness in reducing PPH-related maternal bleeding events and deaths. We conducted a cohort study including parturient women at high risk of bleeding after undergoing a cesarean section (CS). Participants were divided into two groups: the treatment group received prophylactic 1-g TxA before surgery (n = 500), while the comparison group underwent CS without TxA treatment (n = 500). The primary outcome measured increased maternal blood loss following CS, defined as more than a 10% drop in hemoglobin concentration within 24 h post-CS and/or a drop of ≥2 g/dL in maternal hemoglobin concentration. Secondary outcomes included PPH indicators, ICU admission, hospital stay, TxA complications, and neonatal data. TxA administration significantly reduced hemoglobin decrease by more than 10%: there was a 35.4% decrease in the TxA group vs. a 59.4% decrease in the non-TxA group, p < 0.0001 and hemoglobin decreased by ≥2 g/dL (11.4% in the TxA group vs. 25.2% in non-TxA group, p < 0.0001), reduced packed red blood cell transfusion (p = 0.0174), and resulted in lower ICU admission rates (p = 0.034) and shorter hospitalization (p < 0.0001). Complication rates and neonatal outcomes did not differ significantly. In conclusion, prophylactic TxA administration during high-risk CS may effectively reduce blood loss, providing a potential intervention to improve maternal outcomes.
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Affiliation(s)
- Yair Binyamin
- Department of Anesthesiology, Soroka University Medical Center, The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84101, Israel; (I.G.); (A.Z.)
| | - Amit Frenkel
- General Intensive Care Department, Soroka University Medical Center, The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84101, Israel; (A.F.); (Y.B.)
| | - Igor Gruzman
- Department of Anesthesiology, Soroka University Medical Center, The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84101, Israel; (I.G.); (A.Z.)
| | - Sofia Lerman
- Department of Anesthesiology, Soroka University Medical Center, The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84101, Israel; (I.G.); (A.Z.)
| | - Yoav Bichovsky
- General Intensive Care Department, Soroka University Medical Center, The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84101, Israel; (A.F.); (Y.B.)
| | - Alexander Zlotnik
- Department of Anesthesiology, Soroka University Medical Center, The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84101, Israel; (I.G.); (A.Z.)
| | - Michael Y. Stav
- Department of Anesthesia, Beilinson Hospital, Rabin Medical Center Associated with Sakler Medical School, Tel Aviv University, Tel Aviv 6423906, Israel; (M.Y.S.); (S.O.-Z.)
| | - Offer Erez
- Division of Obstetrics and Gynecology, Soroka University Medical Center, The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84101, Israel;
| | - Sharon Orbach-Zinger
- Department of Anesthesia, Beilinson Hospital, Rabin Medical Center Associated with Sakler Medical School, Tel Aviv University, Tel Aviv 6423906, Israel; (M.Y.S.); (S.O.-Z.)
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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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Assis IDC, Govêia CS, Miranda DB, Ferreira RS, Riccio LGC. Analysis of the efficacy of prophylactic tranexamic acid in preventing postpartum bleeding: systematic review with meta-analysis of randomized clinical trials. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2022:S0104-0014(22)00103-8. [PMID: 35995323 PMCID: PMC10362441 DOI: 10.1016/j.bjane.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 07/28/2022] [Accepted: 08/05/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Postpartum Hemorrhage (PPH) is one of the main causes of maternal mortality, mainly in the poorest regions of the world, drawing attention to the need for strategies for preventing it. This study aims to evaluate the efficacy of prophylactic administration of Tranexamic Acid (TXA) in decreasing blood loss in pregnant women in delivery, preventing PPH. METHODS Systematic review of randomized clinical trials. We searched for publications in PubMed, EMBASE and Cochrane Library databases, with the uniterms "postpartum, puerperal hemorrhage" and "tranexamic acid", published between January of 2004 and January of 2020. The eligibility criteria were trials published in English with pregnant women assessed during and after vaginal or cesarean delivery about the effect of prophylactic use of TXA on bleeding volume. The random-effects model was applied with the DerSimonian-Laird test and the Mean Difference (MD) was calculated for continuous variables together with each 95% CI. This systematic review was previously registered in the PROSPERO platform under the registration n° CRD42020187393. RESULTS Of the 630 results, 16 trials were selected, including one with two different doses, performing a total of 6731 patients. The intervention group received a TXA dose that varied between 10 mg.kg-1 and 1g (no weight calculation). The TXA use was considered a protective factor for bleeding (MD: -131.07; 95% CI: -170.00 to -92.78; p = 0.000) and hemoglobin variation (MD: -0.417; 95% CI: -0.633 to -0.202; p = 0.000). In the subgroup analysis related to the cesarean pathway, the effect of TXA was even greater. CONCLUSION The prophylactic use of tranexamic acid is effective in reducing the post-partum bleeding volume. PROSPERO REGISTRATION ID CRD42020187393.
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Affiliation(s)
- Ivo de C Assis
- Universidade de Brasília, Centro de Anestesiologia do Hospital Universitário, Brasília, Brazil.
| | - Catia S Govêia
- Hospital de Base do Distrito Federal, Departamento de Oftalmologia, Brasilia, DF, Brazil
| | - Denismar B Miranda
- Hospital de Base do Distrito Federal, Departamento de Oftalmologia, Brasilia, DF, Brazil
| | - Rafael S Ferreira
- Universidade de Brasília, Centro de Anestesiologia do Hospital Universitário, Brasília, Brazil
| | - Luiza G C Riccio
- Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, BR
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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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8
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Bellos I, Pergialiotis V. Tranexamic acid for the prevention of postpartum hemorrhage in women undergoing cesarean delivery: an updated meta-analysis. Am J Obstet Gynecol 2022; 226:510-523.e22. [PMID: 34582795 DOI: 10.1016/j.ajog.2021.09.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/16/2021] [Accepted: 09/21/2021] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Ioannis Bellos
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - Vasilios Pergialiotis
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Hurskainen T, Deng MX, Etherington C, Burns JK, Martin Calderon L, Moher D, Edwards W, Boet S. Tranexamic acid for prevention of bleeding in cesarean delivery: An overview of systematic reviews. Acta Anaesthesiol Scand 2022; 66:3-16. [PMID: 34514595 DOI: 10.1111/aas.13981] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 08/20/2021] [Accepted: 08/24/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Bleeding is the leading cause of maternal mortality in the world. Tranexamic acid reduces bleeding in trauma and surgery. Several systematic reviews of randomized trials have investigated tranexamic acid in the prevention of bleeding in cesarean delivery. However, the conclusions from systematic reviews are conflicting. This overview aims to summarize the evidence and explore the reasons for conflicting conclusions across the systematic reviews. METHODS A comprehensive literature search of Medline, Embase, and Cochrane Database of Systematic Reviews was conducted from inception to April 2021. Screening, data extraction, and quality assessments were performed by two independent reviewers. A Measurement Tool to Assess Reviews 2 and the Risk of Bias Assessment Tool for Systematic Reviews were used for study appraisal. A qualitative synthesis of evidence is presented. RESULTS In all, 14 systematic reviews were included in our analysis. Across these reviews, there were 32 relevant randomized trials. A modest reduction in blood transfusions and bleeding outcomes was found by most systematic reviews. Overall confidence in results varied from low to critically low. All of the included systematic reviews were at high risk of bias. Quality of evidence from randomized trials was uncertain. CONCLUSIONS Systematic reviews investigating prophylactic tranexamic acid in cesarean delivery are heterogeneous in terms of methodological and reporting quality. Tranexamic acid may reduce blood transfusion and bleeding outcomes, but rigorous well-designed research is needed due to the limitations of the included studies. Data on safety and adverse effects are insufficient to draw conclusions.
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Affiliation(s)
- Tomi Hurskainen
- Department of Anesthesiology The Ottawa HospitalUniversity of Ottawa Ottawa Ontario Canada
- Division of Anesthesiology Department of Anesthesiology, Intensive Care and Pain Medicine Helsinki University Hospital Helsinki Finland
| | - Mimi X. Deng
- School of Medicine University of Ottawa Ottawa Ontario Canada
| | - Cole Etherington
- Ottawa Hospital Research Institute – Centre for Practice Changing Research Ottawa Ontario Canada
| | - Joseph K. Burns
- Clinical Research Assistant Clinical Epidemiology Program Ottawa Hospital Research Institute Ottawa Ontario Canada
| | | | - David Moher
- Knowledge Synthesis Group Clinical Epidemiology Program Ottawa Hospital Research Institute Ottawa Ontario Canada
- School of Epidemiology and Public Health University of Ottawa Ottawa Ontario Canada
| | - Wesley Edwards
- Department of Anesthesia and Pain Medicine The Ottawa Hospital Ottawa Ontario Canada
- Faculty of Medicine University of Ottawa Ottawa Ontario Canada
| | - Sylvain Boet
- Department of Anesthesiology and Pain Medicine The Ottawa Hospital Research InstituteThe Ottawa HospitalGeneral Campus Ottawa Ontario Canada
- Department of Innovation in Medical Education The Ottawa Hospital Research InstituteThe Ottawa HospitalGeneral Campus Ottawa Ontario Canada
- Faculty of Medicine Francophone Affairs Ottawa Ontario Canada
- Institut du savoir Montfort Ottawa Ontario Canada
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10
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Colomina MJ, Contreras L, Guilabert P, Koo M, Méndez E, Sabate A. Clinical use of tranexamic acid: evidences and controversies. Braz J Anesthesiol 2021; 72:795-812. [PMID: 34626756 DOI: 10.1016/j.bjane.2021.08.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 08/03/2021] [Accepted: 08/08/2021] [Indexed: 11/26/2022] Open
Abstract
Tranexamic acid (TXA) significantly reduces blood loss in a wide range of surgical procedures and improves survival rates in obstetric and trauma patients with severe bleeding. Although it mainly acts as a fibrinolysis inhibitor, it also has an anti-inflammatory effect, and may help attenuate the systemic inflammatory response syndrome found in some cardiac surgery patients. However, the administration of high doses of TXA has been associated with seizures and other adverse effects that increase the cost of care, and the administration of TXA to reduce perioperative bleeding needs to be standardized. Tranexamic acid is generally well tolerated, and most adverse reactions are considered mild or moderate. Severe events are rare in clinical trials, and literature reviews have shown tranexamic acid to be safe in several different surgical procedures. However, after many years of experience with TXA in various fields, such as orthopedic surgery, clinicians are now querying whether the dosage, route and interval of administration currently used and the methods used to control and analyze the antifibrinolytic mechanism of TXA are really optimal. These issues need to be evaluated and reviewed using the latest evidence to improve the safety and effectiveness of TXA in treating intracranial hemorrhage and bleeding in procedures such as liver transplantation, and cardiac, trauma and obstetric surgery.
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Affiliation(s)
- Maria J Colomina
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain; Barcelona University, Barcelona, Spain.
| | - Laura Contreras
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain
| | - Patricia Guilabert
- Universitat Autònoma de Barcelona, Vall d'Hebron University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain
| | - Maylin Koo
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain; Barcelona University, Barcelona, Spain
| | - Esther Méndez
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain
| | - Antoni Sabate
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain; Barcelona University, Barcelona, Spain
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11
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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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12
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Kashanian M, Dadkhah F, Tabatabaei N, Sheikhansari N. Effects of tranexamic acid on the amount of bleeding following vaginal delivery and its adverse effects: a double-blind placebo controlled randomized clinical trial. J Matern Fetal Neonatal Med 2021; 35:5611-5615. [PMID: 34024233 DOI: 10.1080/14767058.2021.1888911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
INTRODUCTION Postpartum hemorrhage (PPH) is the most important concern after delivery. Tranexamic acid (TXA), an anti-fibrinolytic agent, has been suggested for prevention and treatment of PPH. OBJECTIVE The purpose of the present study was to find the effects of TXA on the amount of bleeding following vaginal delivery and its adverse effects. MATERIALS AND METHODS The study was performed as a randomized double blind placebo controlled clinical trial on low risk pregnant women who delivered vaginally. The patients were randomly assigned into two groups. Women in the intervention group received 10 mg/kg infusion of TXA in 100 mL normal saline and the control group received one vial of distilled water (as placebo) in 100 mL normal saline. The primary outcome was amount of bleeding after delivery. The secondary outcomes were decreased in hemoglobin level, need for additional uterotonic agents and need for blood transfusion. All were evaluated 6 h after delivery and compared in the two groups. Participants were followed up to six weeks after delivery for any TXA side effects. RESULTS Two hundred and seven women finished the study. There were no significant differences between the two groups in terms of demographic data and risk factors for bleeding. Mean blood loss and need to misoprostol was more in the control group (p=.033 and p=.000, respectively). Hemoglobin level was higher in the TXA group 6 h after delivery. None of the subjects needed blood transfusion, uterine balloon tamponade or emergency hysterectomy. Adverse effects were higher in the TXA group, however, there were no side effects between weeks 3 and 6 in both groups. There were no thromboembolic events during six weeks after delivery. CONCLUSIONS Tranexamic acid can reduce the amount of bleeding after vaginal delivery in low risk women without having serious complications. Also, it may decrease the need for additional uterotonic agents. Trial registration number and registry website: IRCT20091023002624N22.
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Affiliation(s)
- Maryam Kashanian
- Department of Obstetrics & Gynecology, Akbarabadi Teaching Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Farideh Dadkhah
- Department of Obstetrics & Gynecology, Firoozgar Teaching Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Nasim Tabatabaei
- Department of Obstetrics & Gynecology, Akbarabadi Teaching Hospital, Iran University of Medical Sciences, Tehran, Iran
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13
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Koh A, Adiamah A, Gomez D, Sanyal S. Safety and efficacy of tranexamic acid in minimizing perioperative bleeding in extrahepatic abdominal surgery: meta-analysis. BJS Open 2021; 5:6220258. [PMID: 33839754 PMCID: PMC8038263 DOI: 10.1093/bjsopen/zrab004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/06/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Perioperative bleeding is associated with increased morbidity and mortality in patients undergoing elective abdominal surgery. The antifibrinolytic agent tranexamic acid (TXA) has been shown to reduce perioperative bleeding and mortality risk in patients with traumatic injuries, but there is a lack of evidence for its use in elective abdominal and pelvic surgery. This meta-analysis of RCTs evaluated the effectiveness and safety of TXA in elective extrahepatic abdominopelvic surgery. METHODS PubMed, Embase, and ClinicalTrial.gov databases were searched to identify relevant RCTs from January 1947 to May 2020. The primary outcome, intraoperative blood loss, and secondary outcomes, need for perioperative blood transfusion, units of blood transfused, thromboembolic events, and mortality, were extracted from included studies. Quantitative pooling of data was based on a random-effects model. RESULTS Some 19 studies reporting on 2205 patients who underwent abdominal, pelvic, gynaecological or urological surgery were included. TXA reduced intraoperative blood loss (mean difference -188.35 (95 per cent c.i. -254.98 to -121.72) ml) and the need for perioperative blood transfusion (odds ratio (OR) 0.43, 95 per cent c.i. 0.28 to 0.65). TXA had no impact on the incidence of thromboembolic events (OR 0.49, 0.18 to 1.35). No adverse drug reactions or in-hospital deaths were reported. CONCLUSION TXA reduces intraoperative blood loss during elective extrahepatic abdominal and pelvic surgery without an increase in complications.
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Affiliation(s)
- A Koh
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - A Adiamah
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - D Gomez
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - S Sanyal
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
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14
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Sentilhes L, Daniel V, Deneux-Tharaux C. TRAAP2 - TRAnexamic Acid for Preventing postpartum hemorrhage after cesarean delivery: a multicenter randomized, doubleblind, placebo- controlled trial - a study protocol. BMC Pregnancy Childbirth 2020; 20:63. [PMID: 32005192 PMCID: PMC6995226 DOI: 10.1186/s12884-019-2718-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 12/30/2019] [Indexed: 12/28/2022] Open
Abstract
Background An antifibrinolytic agent that blocks lysine-binding sites on plasminogen molecules, tranexamic acid reduces bleeding-related mortality in women with postpartum hemorrhage (PPH), especially administered fairly soon after delivery. According to the randomized controlled trials thus far reported for PPH prevention after cesarean deliveries (n = 16), women who received tranexamic acid had significantly less postpartum blood loss and no increase in severe adverse effects. These were, however, primarily small single-center studies that had fundamental methodological flaws. Multicenter randomized controlled trials with adequate power are necessary to demonstrate its value persuasively before tranexamic acid goes into widespread use for the prevention of PPH after cesarean deliveries. Methods/design This study will be a multicenter, double-blind, randomized controlled trial with two parallel groups including 4524 women with cesarean deliveries before or during labor, at a term ≥34 weeks, modeled on our previous study of tranexamic acid administered after vaginal deliveries. Treatment (either tranexamic acid 1 g or placebo) will be administered intravenously just after birth. All women will also receive a prophylactic uterotonic agent. The primary outcome will be the incidence of PPH, defined by a calculated estimated blood loss > 1000 mL or a red blood cell transfusion before day 2 postpartum. This study will have 80% power to show a 20% reduction in the incidence of PPH, from 15.0 to 12.0%. Discussion As an, inexpensive, easy to administer drug that can be add to the routine management of cesarean births in delivery rooms, tranexamic acid is a promising candidate for preventing PPH after these births. This large, adequately powered, multicenter randomized placebo-controlled trial seeks to determine if the benefits of the routine prophylactic use of tranexamic acid after cesarean delivery significantly outweigh its risks. Trial registration ClinicalTrials.gov NCT03431805 (February 12, 2018).
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Affiliation(s)
- Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Place Amélie Raba Léon, 33076, Bordeaux, France. .,Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest (PPRIGO), Brest, France.
| | - Valérie Daniel
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Place Amélie Raba Léon, 33076, Bordeaux, France.,Department of pharmacy, Angers University Hospital, Angers, France
| | - Catherine Deneux-Tharaux
- INSERM U1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Statistics, Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
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15
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Houston BL, Uminski K, Mutter T, Rimmer E, Houston DS, Menard CE, Garland A, Ariano R, Tinmouth A, Abou-Setta AM, Rabbani R, Neilson C, Rochwerg B, Turgeon AF, Falk J, Breau RH, Fergusson DA, Zarychanski R. Efficacy and Safety of Tranexamic Acid in Major Non-Cardiac Surgeries at High Risk for Transfusion: A Systematic Review and Meta-Analysis. Transfus Med Rev 2020; 34:51-62. [DOI: 10.1016/j.tmrv.2019.10.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 09/06/2019] [Accepted: 10/02/2019] [Indexed: 12/14/2022]
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16
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Sentilhes L, Madar H, Mattuizzi A, Froeliger A, Merlot B, Elleboode B, Deneux-Tharaux C. Tranexamic acid for childbirth: why, when, and for whom. Expert Rev Hematol 2019; 12:753-761. [DOI: 10.1080/17474086.2019.1642744] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - Hugo Madar
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - Aurélien Mattuizzi
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - Alizée Froeliger
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - Benjamin Merlot
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - Benoit Elleboode
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - Catherine Deneux-Tharaux
- INSERM U1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Statistics Sorbonne Paris Cité, Paris Descartes University, Paris, France
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17
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Wang Y, Liu S, He L. Prophylactic use of tranexamic acid reduces blood loss and transfusion requirements in patients undergoing cesarean section: A meta-analysis. J Obstet Gynaecol Res 2019; 45:1562-1575. [PMID: 31237747 DOI: 10.1111/jog.14013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 05/15/2019] [Indexed: 12/01/2022]
Abstract
AIM Tranexamic acid (TXA) has been used to treat peripartum hemorrhage, while preoperative use of TXA in cesarean section (CS) remains controversial. To assess the effectiveness and safety of prophylactic application of TXA, a meta-analysis was performed. METHODS Electronic databases (MEDLINE [PubMed], Cochrane central register of controlled trials and Embase) were searched up to November 2018. The relevant data and quality of included trail were analyzed by RevMan 5.3. The study was registered at PROSPERO (CRD42018111165). RESULTS Twenty-one randomized controlled trials with a total of 3852 patients were included. Only one research reported thromboembolic events. Compared with control groups, the intra-operative blood loss (mean difference [MD] -155.23 mL, 95% confidence interval [CI] -195.64 - 114.81; P<0.01), postoperative blood loss (MD -26.67 mL, 95% CI -32.98 to -20.36; P<0.01), total blood loss (MD -184.88 mL, 95% CI -218.83 to -150.94; P<0.01), transfusion requirements (relative risk [RR] 0.29, 95% CI 0.18-0.49, P<0.01), massive hemorrhage (RR 0.39, 95% CI 0.30 to 0.51; P<0.01) and additional uterotonic agents use (RR 0.40, 95% CI 0.30-0.55, P<0.01) were markedly reduced in TXA-treated patients. Besides, TXA yielded a significant reduction in hemoglobin drop (MD -0.80 g/dL, 95% CI -1.07 to -0.53; P<0.01) and hematocrit drop (MD -2.05, 95% CI -3.09 to -1.01; P<0.01) compared with control groups. CONCLUSION Prophylactic application of TXA can decrease perioperative blood loss and transfusion requirements in patients undergoing CS. More high-quality researches are needed to determine optimal dose of the drug.
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Affiliation(s)
- Yongjun Wang
- Transfusion Department, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Siyuan Liu
- Transfusion Department, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Li He
- Transfusion Department, The Second Xiangya Hospital, Central South University, Changsha, China
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18
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Yates J, Perelman I, Khair S, Taylor J, Lampron J, Tinmouth A, Saidenberg E. Exclusion criteria and adverse events in perioperative trials of tranexamic acid: a systematic review and meta-analysis. Transfusion 2018; 59:806-824. [PMID: 30516835 DOI: 10.1111/trf.15030] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 10/01/2018] [Accepted: 10/06/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) is an inexpensive therapy effective at minimizing perioperative blood loss and transfusion. However, it remains underutilized due to safety concerns. To date, no evidence-based guidelines exist identifying which patients should not receive TXA therapy. This study determined patient groups for whom safety information regarding TXA is lacking due to common exclusion from perioperative TXA trials. STUDY DESIGN AND METHODS A systematic review searching the databases Medline, EMBASE, CENTRAL, and Clinicaltrials.gov was performed. Randomized controlled trials (RCTs) administering systemic TXA perioperatively to elective or emergent surgery patients were eligible. Our primary outcome was to describe exclusion criteria of RCTs, and the secondary outcome was TXA safety. A descriptive synthesis of exclusion criteria was performed, and TXA safety was assessed by meta-analysis. RESULTS A total of 268 eligible RCTs were included. Meta-analysis showed that systemic TXA did not increase risk of adverse events compared to placebo or no intervention (relative risk, 1.05; 95% confidence interval, 0.99-1.12). Patient groups commonly excluded from perioperative TXA trials, and thus potentially lacking TXA safety data, were those with major comorbidities, a history of thromboembolism, medication use affecting coagulation, TXA allergy, and coagulopathy. Exclusion of patients with major comorbidities may not be necessary; we showed that the risk of adverse events was similar in studies that excluded patients with major comorbidities and those that did not. CONCLUSION Sufficient evidence exists to develop perioperative guidelines for TXA use in many populations. Further studies evaluating perioperative TXA use in patients with a history of thromboembolism are warranted.
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Affiliation(s)
- Jeffrey Yates
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Iris Perelman
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Simonne Khair
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Joshua Taylor
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jacinthe Lampron
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alan Tinmouth
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital, Ottawa, Ontario, Canada
| | - Elianna Saidenberg
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital, Ottawa, Ontario, Canada
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19
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Safety and efficacy of tranexamic acid for prevention of obstetric haemorrhage: an updated systematic review and meta-analysis. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2018; 16:329-337. [PMID: 29757132 DOI: 10.2450/2018.0026-18] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 03/08/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND A number of clinical systematic review and meta-analysis have been published on the use of tranexamic in the obstetric setting. The aim of this meta-analysis was to evaluate the safety and effectiveness of tranexamic acid in reducing blood loss when given prior to caesarean delivery. MATERIALS AND METHODS We searched the Cochrane Wounds Specialized Register, Cochrane Central, MEDLINE (through PUBMED), Embase, and SCOPUS electronic databases. We also searched clinical trials registries for ongoing and unpublished studies, and checked reference lists to identify additional studies. We used no restrictions with respect to language and date of publication. Two review authors independently performed study selection, "Risk of bias" assessment, and data extraction. Initial disagreements were resolved by discussion, or by including a third review author when necessary. RESULTS We found 18 randomised controlled trials (RCTs) that met our inclusion criteria. Overall, 1,764 women receiving intravenous tranexamic acid for prevention of bleeding following caesarean sections and 1,793 controls receiving placebo were enrolled in the 18 RCTs evaluated. The use of tranexamic acid compared to controls (placebo or no intervention) reduces post-partum haemorrhage >400 mL (risk ratio [RR] 0.40, 95% confidence interval [CI] 0.24-0.65; 5 trials with a total of 786 participants), severe post-partum haemorrhage >1,000 mL (RR 0.32, 95% CI: 0.12-0.84; 5 trials with a total of 1,850 participants), and need for red blood cell transfusion (RR 0.30, 95% CI: 0.18-0.49; 10 trials with a total of 1,873 participants). No particular safety concerns on the use of this antifibrinolytic agent emerged from the analysis of the 18 RCTs included. DISCUSSION Overall, the results of this meta-analysis support the evidence of a beneficial effect of tranexamic acid in reducing blood loss and need for blood transfusion in pregnant women undergoing caesarean section.
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20
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Li C, Gong Y, Dong L, Xie B, Dai Z. Is prophylactic tranexamic acid administration effective and safe for postpartum hemorrhage prevention?: A systematic review and meta-analysis. Medicine (Baltimore) 2017; 96:e5653. [PMID: 28072700 PMCID: PMC5228660 DOI: 10.1097/md.0000000000005653] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND To assess the efficacy and safety of tranexamic acid (TA) in reducing blood loss and lowering transfusion needs for patients undergoing caesarean section (CS) or vaginal delivery (VD). METHODS An electronic literature search of PubMed, EMBASE, OVID, Cochrane library, Scopus, Central, and Clinical trials.gov was performed to identify studies that evaluating the usage of TA in CS or VD. The methodological quality of included trials was assessed and data extraction was performed. RESULTS Finally, 25 articles with 4747 participants were included. Our findings indicated TA resulted in a reduced intra-, postoperative, and total blood loss by a mean volume of 141.25 mL (95% confidence interval [CI] -186.72 to -95.79, P < 0.00001), 36.42 mL (95% CI -46.50 to -26.34, P < 0.00001), and 154.25 mL (95% CI -182.04 to -126.47, P < 0.00001) in CS. TA administration in VD was associated with a reduced intra-, postoperative, and total blood loss by a mean volume of 22.88 mL (95% CI -50.54 to 4.77, P = 0.10), 41.24 mL (95% CI -55.50 to -26.98, P < 0.00001), and 84.79 mL (95% CI -109.93 to -59.65, P < 0.00001). In addition, TA could lower the occurrence rate of postpartum hemorrhage (PPH) and severe PPH, and reduce the risk of blood transfusions. No increased risk of deep vein thrombosis (DVT) after CS or VD was associated with TA usage, while the minor side effects were more common. CONCLUSIONS Our findings indicated that intravenous TA for patients undergoing CS was effective and safe. Although prophylactic TA administration is associated with reduced PPH, current existing data are insufficient to draw definitive recommendations about its clinical significance due to the poor to moderate quality of the included literatures. Thus, high-quality randomized controlled trials with larger samples are needed to validate our findings.
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Affiliation(s)
- Chunbo Li
- Department of Obstetrics and Gynaecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine
| | - Yuping Gong
- Department of Nursing, Zhongshan Hospital of Fudan University
| | - Lingling Dong
- Department of Obstetrics and Gynaecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine
| | - Bingying Xie
- Department of Gynaecology and Obstetrics, Gynaecology and Obstetrics Hospital of Fudan University, Shanghai, China
| | - Zhiyuan Dai
- Department of Obstetrics and Gynaecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine
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