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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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Munoz JL, Blankenship LM, Ramsey PS, McCann GA. Implementation and outcomes of a uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum. Am J Obstet Gynecol 2023; 229:61.e1-61.e7. [PMID: 36965865 DOI: 10.1016/j.ajog.2023.03.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND Placenta accreta spectrum disorders are a continuum of placental pathologies with significant maternal morbidity and mortality. Morbidity is related to the overall degree of placental adherence, and thus patients with placenta increta or percreta represent a high-risk category of patients. Hemorrhage and transfusion of blood products represent 90% of placenta accreta spectrum morbidity. Both tranexamic acid and uterine artery embolization independently decrease obstetrical hemorrhage. OBJECTIVE This study aimed to provide an evidence-based intraoperative protocol for placenta accreta spectrum management. STUDY DESIGN This study was a pre- and postimplementation analysis of concomitant uterine artery embolization and tranexamic acid in cases of patients with antenatally suspected placenta increta and percreta over a 5-year period (2018-2022). For comparison, a 5-year (2013-2017) preimplementation group was used to assess the impact of the uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum. Patient demographics and clinically relevant outcomes were obtained from electronic medical records. RESULTS A total of 126 cases were managed by the placenta accreta spectrum team, of which 66 had suspected placenta increta/percreta over the 10-year time period. Two patients were excluded from the postimplementation cohort because they did not undergo both interventions. Thus, 30 (30/64; 47%) were treated after implementation of the uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum, and 34 (34/64; 53%) preimplementation patients did not undergo uterine artery embolization or tranexamic acid infusion. With the uterine artery embolization and tranexamic acid protocol, operative times were longer (416 vs 187 minutes; P<.01), and patients were more likely to receive general anesthesia (80% vs 47%; P<.01). However, blood loss was reduced by 33% (2000 vs 3000 cc; P=.03), overall blood transfusion rates decreased by 51% (odds ratio, 0.05 [95% confidence interval, 0.001-0.20]; P<.01), and massive blood transfusion (>10 units transfused) was reduced 5-fold (odds ratio, 0.17 [95% confidence interval, 0.02-0.17]; P=.02). Postoperative complication rates remained unchanged (4 vs 10 events; P=.14). Neonatal outcomes were equivalent. CONCLUSION The uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum is an effective approach to the standardization of complex placenta accreta spectrum cases that results in optimal perioperative outcomes and reduced maternal morbidity.
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Affiliation(s)
- Jessian L Munoz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Logan M Blankenship
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Texas Health Science Center at San Antonio, University Health System, San Antonio, TX
| | - Patrick S Ramsey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Health Science Center at San Antonio, University Health System, San Antonio, TX
| | - Georgia A McCann
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Texas Health Science Center at San Antonio, University Health System, San Antonio, TX
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Akpan UB, Ugwuoke O, Ekpo E, Omoronyia E, Ekabua J. Effectiveness of Combined Preoperative Sublingual Misoprostol and Intravenous Tranexamic Acid on Intraoperative Blood Loss During Elective Caesarean Section: A Randomised, Blinded, Placebo-Controlled Trial. Cureus 2023; 15:e41041. [PMID: 37519499 PMCID: PMC10373943 DOI: 10.7759/cureus.41041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 08/01/2023] Open
Abstract
INTRODUCTION The objective of this study was to evaluate the effect of preoperative administration of sublingual misoprostol and intravenous tranexamic acid (TXA) on intraoperative blood loss during elective caesarean sections. METHODS This was a double-blinded, randomised, placebo-controlled study involving 116 women scheduled for elective caesarean sections. The treatment arm, group 1 (n=58), received 1000 mg of intravenous tranexamic acid 10-15 minutes before skin incision and 600 mcg of sublingual misoprostol after sub-arachnoid anaesthesia and before skin incision. Group 2 (n=58) received placebos; both groups had oxytocin injections at the delivery of the placenta. The data were analyzed using IBM® Statistical Package for the Social Sciences (SPSS) version 24 (IBM Corp., Armonk, NY). RESULTS The primary outcome was the intraoperative blood loss and the difference between preoperative and postoperative hematocrit values in both groups. The mean intraoperative blood loss was significantly lower in the study group than in the control group (308.552 ± 42.991 mL versus 736.414 ± 171.889 mL, p<0.001). The differences between the preoperative and post-operative hematocrit values were also significantly lower in the study group than in the control group (2.212% ± 0.805% versus 5.660% ± 2.496%, p<0.001). CONCLUSION Preoperative administration of 1000 mg of intravenous tranexamic acid and 600 mcg of sublingual misoprostol significantly reduced blood loss related to elective caesarean delivery.
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Affiliation(s)
- Ubong B Akpan
- Department of Obstetrics and Gynaecology, University of Calabar Teaching Hospital, Calabar, NGA
| | - Obinna Ugwuoke
- Department of Obstetrics and Gynaecology, Nigerian Airforce Medical Centre, Calabar, NGA
| | - Edet Ekpo
- Department of Obstetrics and Gynaecology, Universty of Calabar Teaching Hospital, Calabar, NGA
| | - Ezukwa Omoronyia
- Department of Obstetrics and Gynaecology, University of Calabar Teaching Hospital, Calabar, NGA
| | - John Ekabua
- Department of Obstetrics and Gynaecology, University of Calabar Teaching Hospital, Calabar, NGA
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Lourijsen E, Avdeeva K, Gan KL, Pundir V, Fokkens W. Tranexamic acid for the reduction of bleeding during functional endoscopic sinus surgery. Cochrane Database Syst Rev 2023; 2:CD012843. [PMID: 36808096 PMCID: PMC9943060 DOI: 10.1002/14651858.cd012843.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
BACKGROUND Chronic rhinosinusitis, with or without nasal polyps, can have a major impact on a person's quality of life. Treatment is usually conservative and may include nasal saline, intranasal corticosteroids, antibiotics or systemic corticosteroids. If these treatments fail endoscopic sinus surgery can be considered. During surgery, visibility of the surgical field is important for the identification of important anatomic landmarks and structures that contribute to safety. Impaired visualisation can lead to complications during surgery, inability to complete the operation or a longer duration of surgery. Different methods are used to decrease intraoperative bleeding, including induced hypotension, topical or systemic vasoconstrictors or total intravenous anaesthesia. Another option is tranexamic acid, an antifibrinolytic agent, which can be administered topically or intravenously. OBJECTIVES To assess the effects of peri-operative tranexamic acid versus no therapy or placebo on operative parameters in patients with chronic rhinosinusitis (with or without nasal polyps) who are undergoing functional endoscopic sinus surgery (FESS). SEARCH METHODS The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 10 February 2022. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing intravenous, oral or topical tranexamic acid with no therapy or placebo in the treatment of patients (adults and children) with chronic rhinosinusitis, with or without nasal polyps, undergoing FESS. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. Primary outcome measures were surgical field bleeding score (e.g. Wormald or Boezaart grading system), intraoperative blood loss and significant adverse effects (seizures or thromboembolism within 12 weeks of surgery). Secondary outcomes were duration of surgery, incomplete surgery, surgical complications and postoperative bleeding (placing of packing or revision surgery) in the first two weeks after surgery. We performed subgroup analyses for methods of administration, different dosages, different forms of anaesthesia, use of thromboembolic prophylaxis and children versus adults. We evaluated each included study for risk of bias and used GRADE to assess the certainty of the evidence. MAIN RESULTS We included 14 studies in the review, with a total of 942 participants. Sample sizes in the included studies ranged from 10 to 170. All but two studies included adult patients (≥ 18 years). Two studies included children. Most studies had more male patients (range 46.6% to 80%). All studies were placebo-controlled and four studies had three treatment arms. Three studies investigated topical tranexamic acid; the other studies reported the use of intravenous tranexamic acid. For our primary outcome, surgical field bleeding score measured with the Boezaart or Wormald grading score, we pooled data from 13 studies. The pooled result demonstrated that tranexamic acid probably reduces the surgical field bleeding score, with a standardised mean difference (SMD) of -0.87 (95% confidence interval (CI) -1.23 to -0.51; 13 studies, 772 participants; moderate-certainty evidence). A SMD below -0.70 represents a large effect (in either direction). Tranexamic acid may result in a slight reduction in blood loss during surgery compared to placebo with a mean difference (MD) of -70.32 mL (95% CI -92.28 to -48.35 mL; 12 studies, 802 participants; low-certainty evidence). Tranexamic acid probably has little to no effect on the development of significant adverse events (seizures or thromboembolism) within 24 hours of surgery, with no events in either group and a risk difference (RD) of 0.00 (95% CI -0.02 to 0.02; 8 studies, 664 participants; moderate-certainty evidence). However, there were no studies reporting significant adverse event data with a longer duration of follow-up. Tranexamic acid probably results in little difference in the duration of surgery with a MD of -13.04 minutes (95% CI -19.27 to -6.81; 10 studies, 666 participants; moderate-certainty evidence). Tranexamic acid probably results in little to no difference in the incidence of incomplete surgery, with no events in either group and a RD of 0.00 (95% CI -0.09 to 0.09; 2 studies, 58 participants; moderate-certainty evidence) and likely results in little to no difference in surgical complications, again with no events in either group and a RD of 0.00 (95% CI -0.09 to 0.09; 2 studies, 58 participants; moderate-certainty evidence), although these numbers are too small to draw robust conclusions. Tranexamic acid may result in little to no difference in the likelihood of postoperative bleeding (placement of packing or revision surgery within three days of surgery) (RD -0.01, 95% CI -0.04 to 0.02; 6 studies, 404 participants; low-certainty evidence). There were no studies with longer follow-up. AUTHORS' CONCLUSIONS There is moderate-certainty evidence to support the beneficial value of topical or intravenous tranexamic acid during endoscopic sinus surgery with respect to surgical field bleeding score. Low- to moderate-certainty evidence suggests a slight decrease in total blood loss during surgery and duration of surgery. Whilst there is moderate-certainty evidence that tranexamic acid does not lead to more immediate significant adverse events compared to placebo, there is no evidence regarding the risk of serious adverse events more than 24 hours after surgery. There is low-certainty evidence that tranexamic acid may not change postoperative bleeding. There is not enough evidence available to draw robust conclusions about incomplete surgery or surgical complications.
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Affiliation(s)
- Evelijn Lourijsen
- Department of Otorhinolaryngology, Amsterdam UMC location AMC, Amsterdam, Netherlands
| | - Klementina Avdeeva
- Department of Otorhinolaryngology, Amsterdam UMC location AMC, Amsterdam, Netherlands
| | - Kit Liang Gan
- Department of Otorhinolaryngology, Mahkota Medical Centre, Melaka, Malaysia
| | - Vishal Pundir
- Department of Otorhinolaryngology, Maidstone and Tunbridge Wells NHS Trust, Tunbridge Wells, UK
| | - Wytske Fokkens
- Department of Otorhinolaryngology, Amsterdam UMC location AMC, Amsterdam, Netherlands
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Sentilhes L, Madar H, Le Lous M, Sénat MV, Winer N, Rozenberg P, Kayem G, Verspyck E, Fuchs F, Azria E, Gallot D, Korb D, Desbrière R, Le Ray C, Chauleur C, de Marcillac F, Perrotin F, Parant O, Salomon LJ, Gauchotte E, Bretelle F, Sananès N, Bohec C, Mottet N, Legendre G, Letouzey V, Haddad B, Vardon D, Mattuizzi A, Froeliger A, Bouchghoul H, Daniel V, Regueme S, Roussillon C, Georget A, Darsonval A, Benard A, Deneux-Tharaux C. Tranexamic acid for the prevention of blood loss after cesarean among women with twins: a secondary analysis of the TRAnexamic Acid for Preventing Postpartum Hemorrhage Following a Cesarean Delivery randomized clinical trial. Am J Obstet Gynecol 2022; 227:889.e1-889.e17. [PMID: 35724759 DOI: 10.1016/j.ajog.2022.06.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 06/05/2022] [Accepted: 06/08/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Although prophylactic tranexamic acid administration after cesarean delivery resulted in a lower incidence of calculated estimated blood loss of >1000 mL or red cell transfusion by day 2, its failure to reduce the incidence of hemorrhage-related secondary clinical outcomes (TRAnexamic Acid for Preventing Postpartum Hemorrhage Following a Cesarean Delivery trial) makes its use questionable. The magnitude of its effect may differ in women at higher risk of blood loss, including those with multiple pregnancies. OBJECTIVE This study aimed to compare the effect of tranexamic acid vs placebo to prevent blood loss after cesarean delivery among women with multiple pregnancies. STUDY DESIGN This was a secondary analysis of the TRAnexamic Acid for Preventing Postpartum Hemorrhage Following a Cesarean Delivery trial data, a double-blind, randomized controlled trial from March 2018 to January 2020 in 27 French maternity hospitals, that included 319 women with multiple pregnancies. Women with a cesarean delivery before or during labor at ≥34 weeks of gestation were randomized to receive intravenously 1 g of tranexamic acid (n=160) or placebo (n=159), both with prophylactic uterotonics. The primary outcome was a calculated estimated blood loss of >1000 mL or a red blood cell transfusion by 2 days after delivery. The secondary outcomes included clinical and laboratory blood loss measurements. RESULTS Of the 4551 women randomized in this trial, 319 had a multiple pregnancy and cesarean delivery, and 298 (93.4%) had primary outcome data available. This outcome occurred in 62 of 147 women (42.2%) in the tranexamic acid group and 67 of 152 (44.1%) receiving placebo (adjusted risk ratio, 0.97; 95% confidence interval, 0.68-1.38; P=.86). No significant between-group differences occurred for any hemorrhage-related clinical outcomes: gravimetrically estimated blood loss, provider-assessed clinically significant hemorrhage, additional uterotonics, postpartum blood transfusion, arterial embolization, and emergency surgery (P>.05 for all comparisons). CONCLUSION Among women with a multiple pregnancy and cesarean delivery, prophylactic tranexamic acid did not reduce the incidence of any blood loss-related outcomes.
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Affiliation(s)
- Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France.
| | - Hugo Madar
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Maëla Le Lous
- Department of Obstetrics and Gynecology, Rennes University Hospital, Rennes, France
| | - Marie Victoire Sénat
- Department of Obstetrics and Gynecology, Bicêtre University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Norbert Winer
- Department of Obstetrics and Gynecology, University Medical Center of Nantes, Centre d'Investigation Clinique Mère Enfant, University Hospital, Nantes, France; National Institute of Agricultural Research, Unité Mixte de Recherche 1280, Physiology of Nutritional Adaptations, University of Nantes, Institute of Digestive Disease and Centre de Recherche en Nutrition Humaine-Ouest, Nantes, France
| | - Patrick Rozenberg
- Department of Obstetrics and Gynecology, Poissy/Saint-Germain Hospital, Poissy, France
| | - Gilles Kayem
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Centre de Recherche en Épidémiologie et StatistiqueS, Institut National de la Santé et de la Recherche Médicale, Institut National de la Recherche Agronomique, Universitary Hospital Departement - Risks in Pregnancy, Université de Paris, Paris, France; Department of Obstetrics and Gynecology, Trousseau Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Eric Verspyck
- Department of Obstetrics and Gynecology, Rouen University Hospital, Rouen, France
| | - Florent Fuchs
- Department of Obstetrics and Gynecology, Montpellier University Hospital, Montpellier, France; Institut National de la Santé et de la Recherche Médicale, Centre for Research in Epidemiology and Population Health, U1018, Reproduction and Child Development, Villejuif, France
| | - Elie Azria
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Centre de Recherche en Épidémiologie et StatistiqueS, Institut National de la Santé et de la Recherche Médicale, Institut National de la Recherche Agronomique, Universitary Hospital Departement - Risks in Pregnancy, Université de Paris, Paris, France; Maternity Unit, Paris Saint-Joseph Hospital, Paris Descartes University, Paris, France
| | - Denis Gallot
- Department of Obstetrics and Gynecology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Diane Korb
- Department of Obstetrics and Gynecology, Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Raoul Desbrière
- Department of Obstetrics and Gynecology, Saint-Joseph Hospital, Marseille, France
| | - Camille Le Ray
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Centre de Recherche en Épidémiologie et StatistiqueS, Institut National de la Santé et de la Recherche Médicale, Institut National de la Recherche Agronomique, Universitary Hospital Departement - Risks in Pregnancy, Université de Paris, Paris, France; Port Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, Universitéde Paris, Fighting Prematurity University Hospital Federation, Paris, France
| | - Céline Chauleur
- Department of Obstetrics and Gynecology, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Fanny de Marcillac
- Department of Obstetrics and Gynecology, University Hospital of Strasbourg, Strasbourg, France
| | - Franck Perrotin
- Department of Obstetrics and Gynecology, Tours University Hospital, Tours, France
| | - Olivier Parant
- Department of Obstetrics and Gynecology, Toulouse University Hospital, Toulouse, France
| | - Laurent J Salomon
- Department of Obstetrics and Gynecology, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Emilie Gauchotte
- Department of Obstetrics and Gynecology, Nancy University Hospital, Nancy, France
| | - Florence Bretelle
- Department of Obstetrics and Gynecology, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Nicolas Sananès
- Department of Obstetrics and Gynecology, Hôpital Centre Médico-Chirurgical et Obstétrical, Schiltigheim, France
| | - Caroline Bohec
- Department of Obstetrics and Gynecology, François Mitterrand Hospital, Pau, France
| | - Nicolas Mottet
- Department of Obstetrics and Gynecology, Besançon University Hospital, Besançon, France
| | - Guillaume Legendre
- Department of Obstetrics and Gynecology, Angers University Hospital, Angers, France
| | - Vincent Letouzey
- Department of Obstetrics and Gynecology, Carémeau University Hospital, Nimes, France
| | - Bassam Haddad
- Department of Obstetrics, Gynecology and Reproductive Medicine, University Paris Est Créteil, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Delphine Vardon
- Department of Obstetrics and Gynecology, Caen University Hospital, Caen, France
| | - Aurélien Mattuizzi
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Alizée Froeliger
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Hanane Bouchghoul
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Valérie Daniel
- Department of Pharmacy, Angers University Hospital, Angers, France; Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest, Brest University Hospital, Brest, France
| | - Sophie Regueme
- Department of Clinical Research and Innovation, Bordeaux University Hospital, Bordeaux, France
| | - Caroline Roussillon
- European Clinical Trials Platform & Development, French Clinical Research Infrastructure Network, Department of Clinical Research and Innovation, Bordeaux University Hospital, Bordeaux, France
| | - Aurore Georget
- Epidemiology Unit, Public Health Department, Centre Hospitalier Universitaire Bordeaux, Bordeaux, France
| | - Astrid Darsonval
- Department of Pharmacy, Angers University Hospital, Angers, France; Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest, Brest University Hospital, Brest, France
| | - Antoine Benard
- Epidemiology Unit, Public Health Department, Centre Hospitalier Universitaire Bordeaux, Bordeaux, France
| | - Catherine Deneux-Tharaux
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Centre de Recherche en Épidémiologie et StatistiqueS, Institut National de la Santé et de la Recherche Médicale, Institut National de la Recherche Agronomique, Universitary Hospital Departement - Risks in Pregnancy, Université de Paris, Paris, France
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Binyamin Y, Orbach-Zinger S, Gruzman I, Frenkel A, Lerman S, Zlotnik A, Frank D, Ioscovich A, Erez O, Heesen M. The effect of prophylactic use of tranexamic acid for cesarean section. J Matern Fetal Neonatal Med 2022; 35:9157-9162. [DOI: 10.1080/14767058.2021.2019215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Yair Binyamin
- Department of Anesthesiology, Soroka University Medical Center, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Sharon Orbach-Zinger
- Department of Anesthesia, Beilinson Hospital, Rabin Medical Center associated with Sakler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Igor Gruzman
- Department of Anesthesiology, Soroka University Medical Center, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Amit Frenkel
- Department of Anesthesiology, Soroka University Medical Center, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Sofia Lerman
- Department of Anesthesiology, Soroka University Medical Center, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Alexander Zlotnik
- Department of Anesthesiology, Soroka University Medical Center, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Dmitry Frank
- Department of Anesthesiology, Soroka University Medical Center, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Alexander Ioscovich
- Department of Anesthesiology, Perioperative Medicine and Pain Treatment, Shaare Zedek Medical Center, Hebrew University Hadassah Medical School, Jerusalem, Israel
| | - Offer Erez
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Maternity Department “D”, Division of Obstetrics and Gynecology, Soroka University Medical Center, Beer-Sheva, Israel
- Department of Obstetrics and Gynecology, Hutzel Women’s Hospital, School of Medicine, Wayne State University, Detroit, MI, USA
| | - Michael Heesen
- Department of Anesthesia, Kantonsspital Baden, Baden, Switzerland
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Ogunkua OT, Duryea EL, Nelson DB, Eddins MM, Klucsarits SE, McIntire DD, Leveno KJ. Tranexamic Acid for Prevention of Hemorrhage in Elective Repeat Cesarean Delivery - A Randomized Study. Am J Obstet Gynecol MFM 2022; 4:100573. [PMID: 35038612 DOI: 10.1016/j.ajogmf.2022.100573] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/07/2022] [Accepted: 01/12/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The American College of Obstetricians and Gynecologists states that data is insufficient to recommend Tranexamic acid (TXA) prophylaxis for postpartum hemorrhage. OBJECTIVE This study's objective was to evaluate if prophylactic TXA reduces calculated blood loss versus placebo in women undergoing elective repeat cesarean delivery. STUDY DESIGN A double-blind, randomized, placebo-controlled trial, examining calculated blood loss with prophylactic doses of 1-gram of TXA given before skin incision and after placental delivery and standard uterotonics in women with singleton pregnancies at least 37 weeks' gestation, presenting for their second or third cesarean delivery under neuraxial anesthesia. The primary outcome was calculated blood loss at 24 hours. The calculation was based on the participant's height, weight, and the difference in hematocrit before the start of surgery and 24 hours after delivery. Prespecified secondary outcomes were quantification of maternal coagulation activity during the perioperative course. A sample size of 50 women per group was planned (N=100), based on a meta-analysis of mean reduction in blood loss after TXA. RESULTS 723 women were screened, and 110 women were randomized as follows: 55 to TXA and 55 to placebo. The primary outcome of mean calculated blood for TXA (2274 ± 469 mL) and the placebo group (2407 ± 388 mL), p > 0.05. In the secondary outcomes, D-dimer levels were lower in the TXA group than the placebo group 24 hours after delivery (2.1 ± 1.2 µg/mL versus 4.3 ± 2.4 µg/mL), p < 0.001. CONCLUSIONS Prophylactic tranexamic acid did not decrease mean calculated blood loss. Significantly less participants had calculated blood loss greater than 2000 mL in the tranexamic acid group compared to the placebo group with lower levels of D-dimer at 24 hours.
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Affiliation(s)
- Olutoyosi T Ogunkua
- Departments of Anesthesiology and Pain Management (Drs Ogunkua, Eddins, and Klucsarits) and Obstetrics and Gynecology (Drs Duryea, Nelson, McIntire, and Leveno), The University of Texas Southwestern Medical Center, Dallas, TX..
| | - Elaine L Duryea
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - David B Nelson
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Michelle M Eddins
- Departments of Anesthesiology and Pain Management (Drs Ogunkua, Eddins, and Klucsarits) and Obstetrics and Gynecology (Drs Duryea, Nelson, McIntire, and Leveno), The University of Texas Southwestern Medical Center, Dallas, TX
| | - Shannon E Klucsarits
- Departments of Anesthesiology and Pain Management (Drs Ogunkua, Eddins, and Klucsarits) and Obstetrics and Gynecology (Drs Duryea, Nelson, McIntire, and Leveno), The University of Texas Southwestern Medical Center, Dallas, TX
| | - Donald D McIntire
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
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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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9
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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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Effective tranexamic acid concentration for 95% inhibition of tissue-type plasminogen activator-induced hyperfibrinolysis in full-term pregnant women: a prospective interventional study. Blood Coagul Fibrinolysis 2021; 32:186-193. [PMID: 33470644 DOI: 10.1097/mbc.0000000000001015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Postpartum haemorrhage is the leading cause of maternal mortality and morbidity worldwide. Tranexamic acid (TXA) has been shown to reduce blood loss and blood product transfusion requirements. Despite clinical evidence, further studies are needed to better define the pharmacokinetic and pharmacodynamic characteristics of TXA in pregnant women. The objective of our prospective observational ex-vivo study was to define the effective TXA concentration required to inhibit 95% (EC95) of tissue-type plasminogen activator (t-PA)-induced fibrinolysis in full-term pregnant women. Hyperfibrinolysis was induced by adding supraphysiologic concentration of t-PA to blood samples obtained from 30 full-term pregnant women and 10 healthy nonpregnant female volunteers. Increasing TXA concentrations (0--40 μg/ml) were then spiked into the blood samples and inhibition of fibrinolysis was assessed using the lysis index at 30 min of the ROTEM measured on EXTEM and NATEM tests. Effective TXA concentrations required to achieve EC95 were extrapolated using nonlinear regression. EC95 were compared between groups using an extra sum-of-squares F test. EC95 in pregnant women was 14.7 μg/ml (95% CI 12.4--17.5 μg/ml) on EXTEM and 11.2 μg/ml (95% CI 8.3--15.1 μg/ml) on NATEM tests. These values were significantly higher than those obtained in volunteers: 8.7 μg/ml (95% CI 5.5--13.9 μg/ml) and 6.8 μg/ml (95% CI 5.3--8.8 μg/ml), respectively (both P < 0.001). Our results suggest a higher fibrinolytic potential in pregnant women compared with nonpregnant women.
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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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Byrne B, Ryan K, Lavin M. Current Challenges in the Peripartum Management of Women with von Willebrand Disease. Semin Thromb Hemost 2021; 47:217-228. [PMID: 33636752 DOI: 10.1055/s-0041-1723797] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
For many women, pregnancy and childbirth represent their first major hemostatic challenges. Despite advancements in obstetric care, up to 2 to 5% of all deliveries are complicated by postpartum hemorrhage (PPH). To mitigate bleeding risk, physiological changes occur in pregnancy, including increases in plasma von Willebrand factor (VWF) and factor VIII levels. For women with von Willebrand disease (VWD), these physiological alterations are blunted or absent. As a result, women with VWD have a heightened risk of PPH, both primary (in the first 24 hours) and secondary (>24 hours to 6 to 12 weeks postpartum). Pregnancy and delivery management for women with VWD should therefore be carefully coordinated as part of a multidisciplinary team approach. In the absence of large-scale clinical trials, the management of women with VWD during pregnancy is guided by expert consensus guidelines. Clinical practices internationally are not uniform, and areas of considerable clinical uncertainty exist. Traditional peripartum plasma VWF thresholds for hemostatic cover and therapeutic targets are currently under scrutiny, as PPH is not eliminated in women with VWD who receive replacement therapy. The benefit and optimal duration of postpartum tranexamic acid have yet to be defined, and standardized methods of quantification of blood loss at the time of delivery are currently lacking. In this article, we review the evidence base to date and explore the current clinical challenges in the management of pregnant women with VWD.
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Affiliation(s)
- Bridgette Byrne
- Department of Obstetrics & Gynaecology, Coombe Women and Infants University Hospital, Dublin, Ireland.,Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Kevin Ryan
- Department of Obstetrics & Gynaecology, Coombe Women and Infants University Hospital, Dublin, Ireland.,National Coagulation Centre, St. James' Hospital, Dublin, Ireland
| | - Michelle Lavin
- National Coagulation Centre, St. James' Hospital, Dublin, Ireland.,Irish Centre for Vascular Biology, School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
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13
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Prophylactic use of tranexamic acid for decreasing the blood loss in elective cesarean section: A placebo-controlled randomized clinical trial. J Gynecol Obstet Hum Reprod 2020; 50:101973. [PMID: 33221559 DOI: 10.1016/j.jogoh.2020.101973] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 10/29/2020] [Accepted: 11/03/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Tranexamic acid is used as a known treatment of post-partum hemorrhage both in natural vaginal deliveries and cesarean sections, but its use in elective cesarean as a prophylactic measure to decrease the blood loss is not so common. OBJECTIVE This clinical trial evaluates the efficacy and safety of tranexamic acid in decreasing the bleeding in women undergoing elective cesarean section. METHOD 200 term singleton pregnant women who were scheduled for elective cesarean section were randomized to 2 groups and received a bolus of 1 gm tranexamic acid if body weight was <90 kg and 1.5 g if body weight was >90 kg diluted in 15 ml of 5% dextrose intravenously, or 5 ml of distilled water in 15 ml of 5% dextrose as placebo (before skin incision). Intra-operative and post-operative blood loss and hemoglobin levels were compared. RESULTS Tranexamic acid decreased the mean blood loss by 25.3 % in our studied women. Mean volume of intra-operative blood loss was 391.1 (±67.4) ml in tranexamic acid group and 523.8 (±153.4) ml in control group which was statistically significant lesser with a 132.7 ml difference. Rate of >1000 ml and >500 ml bleeding and need to blood transfusion were also statistically significant lower in tranexamic acid group., mean hemoglobin level was statistically significant lower in placebo group than tranexamic acid group (11.77 ± 0.50 versus 11.31 ± 0.56) 6 h after cesarean section. No adverse reaction was documented. CONCLUSION Prophylactic use of intravenous tranexamic acid decreases the blood loss safely in women undergoing elective cesarean section.
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14
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Phillips JM, van den Anker JN, Ahmadzia HK. Next Generation Medical Management of Postpartum Hemorrhage. Curr Pharm Des 2020; 25:549-555. [PMID: 30894102 DOI: 10.2174/1381612825666190320155337] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 03/18/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Postpartum hemorrhage remains a significant contributor to morbidity and mortality of women of childbearing age worldwide. Trends in both incidence and severity of postpartum hemorrhage are increasing which makes it imperative to identify drugs that could target prevention and/or treatment of these postpartum hemorrhages for women living in high, middle and low-income countries. METHODS We have reviewed current advances in the medical management of postpartum hemorrhage focusing on non-uterotonic therapy. We specifically describe the use and mechanism of action of tranexamic acid (TXA) and fibrinogen concentrate. Furthermore, we address the existing data for using these medications in postpartum hemorrhage, highlighting both strengths and limitations. RESULTS This review describes a new generation of medications that are promising for the prevention and/or treatment of postpartum hemorrhage. For patients at risk for significant hemorrhage, TXA has been shown to reduce intraoperative blood loss and can be given as a prophylactic agent. For the treatment of postpartum hemorrhage, early use of TXA has the potential to reduce mortality. In addition, some data exists supporting the use of fibrinogen concentrate, though more studies are required to help formulate guidelines for its use. CONCLUSION A promising new approach for the management of severe postpartum hemorrhage is using medications that alter coagulation. More data are needed to describe ideal patient populations, dosing, the time of administration, and infusion rate.
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Affiliation(s)
- Jaclyn M Phillips
- The George Washington University, School of Medicine and Health Sciences, Washington, DC, United States
| | - John N van den Anker
- The George Washington University, School of Medicine and Health Sciences, Washington, DC, United States.,Children's National Medical Center, Washington, DC, United States
| | - Homa K Ahmadzia
- The George Washington University, School of Medicine and Health Sciences, Washington, DC, United States
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Rottenstreich A, Regev N, Levin G, Ezra Y, Yagel S, Sompolinsky Y, Mankuta D, Kalish Y, Elchalal U. Factors associated with postcesarean blood transfusion: a case control study. J Matern Fetal Neonatal Med 2020; 35:495-502. [PMID: 32041460 DOI: 10.1080/14767058.2020.1724945] [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: 10/25/2022]
Abstract
Objective: Cesarean delivery (CD) is a known risk factor for postpartum hemorrhage. However, the characteristics associated with post-CD transfusion are not well-established. We aimed to assess blood transfusion rates and associated factors following CD.Methods: A retrospective case-control study of women who underwent CD at a university hospital. The study group comprised all women who received blood transfusion following surgery. A control group of women who did not receive postoperative blood transfusion was assigned in a two-to-one ratio.Results: During study period, the overall post-CD blood transfusion rate was 4.7%. The study group comprised 170 women, and the control group 340. Maternal age (aOR [95% CI]: 1.07 (1.03, 1.11), p = .001), parity (aOR [95% CI]: 1.26 (1.09, 1.47), p = .002), gestational hypertensive disorders (aOR [95% CI]: 4.07 (1.52, 10.91), p = .005), maternal comorbidities (aOR [95% CI]: 4.16 (1.88, 9.1), p < .001), lower predelivery hemoglobin level (aOR [95% CI]: 0.43 (0.34, 0.54), p < .001), and major placental abnormalities (aOR [95% CI]: 2.74 (1.04, 7.18), p = .04) were independently associated with blood transfusion requirement. Intrapartum characteristics associated with blood transfusion requirement included nonelective procedure (aOR [95% CI]: 3.21 (1.72, 5.99), p < .001), prolonged second stage of labor (aOR [95% CI]: 5.50 (2.57, 11.78), p < .001), longer duration of surgery (aOR [95% CI]: 1.03 (1.02, 1.04), p < .001), general anesthesia (aOR [95% CI]: 2.11 (1.14, 3.91), p = .02), and greater estimated operative blood loss (aOR [95% CI]: 5.72 (3.15, 10.36), p < .001).Conclusions: Among women who underwent CD, we identified 11 factors associated with blood transfusion following surgery. Prospective studies are warranted to assess the implementations of prophylactic interventions to reduce transfusion rates among those deemed at high risk for CD-related bleeding.
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Affiliation(s)
- Amihai Rottenstreich
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Noam Regev
- Faculty of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Gabriel Levin
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Yossef Ezra
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Simcha Yagel
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Yishay Sompolinsky
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - David Mankuta
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Yosef Kalish
- Department of Hematology, Hadassah, Hebrew University Medical Center, Jerusalem, Israel
| | - Uriel Elchalal
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Bilateral uterine artery ligation plus intravenous tranexamic acid during cesarean delivery for placenta previa: a randomized double-blind controlled trial. J Gynecol Obstet Hum Reprod 2019; 48:115-119. [DOI: 10.1016/j.jogoh.2018.10.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/27/2018] [Accepted: 10/31/2018] [Indexed: 11/21/2022]
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Sahu J, Mishra N. Role of intravenous tranexamic acid in reducing blood loss during caesarean section: Study at tribal-dominated area hospital in Chhattisgarh, India. J Obstet Gynaecol Res 2019; 45:841-848. [PMID: 30663200 DOI: 10.1111/jog.13915] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 12/08/2018] [Indexed: 11/29/2022]
Abstract
AIM To evaluate the effect of low dose (1 g) of intravenous tranexamic acid (TXA) before caesarean delivery upon the mean blood loss during and after surgery as well side effects of the drug and to compare these effects with those who did not receive this medication in a referral hospital situated at the tribal terrain of Chhattisgarh. METHODS Total 100 women fulfilling inclusion criteria and shifted for caesarean section were studied. Fifty women comprising the study group were given one gram TXA (10 mL) intravenously over 10-20 min before skin incision whereas the other 50 women did not receive the drug (control group). Active Management of the Third Stage of Labor was done in all using 10 units of oxytocin intramuscularly within one minute of delivery of baby. The blood loss was quantified by the combination of gravimetric and direct measurement. RESULTS The mean blood loss (intra as well as postoperative) was 436.5 ± 118.07 mL in the study group in comparison to 616.5 ± 153.34 mL in the control group (P ≤ 0.05), only two (4%) women had a blood loss >500 mL during surgery versus nine (18%) (P ≤ 0.05), none versus three (6%) had PPH and postoperative mean change in the hemoglobin was 0.494 ± 0.12 g % versus 0.594 ± 0.16 g % (P ≤ 0.05) in the study and control groups, respectively. No adverse effects were reported in women or neonates. CONCLUSION TXA is a cheap, easily available antifibrinolytic drug that significantly reduces the intra and postoperative blood loss in caesarean section and is very useful for low resource settings.
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Affiliation(s)
- Jaiprakash Sahu
- Department of Obstetrics & Gynaecology, Govt Medical College, Ambikapur, India
| | - Nalini Mishra
- Department of Obstetrics & Gynaecology, Govt Medical College, Ambikapur, India
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18
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Tranexamic Acid for Prevention and Treatment of Postpartum Hemorrhage: An Update on Management and Clinical Outcomes. Obstet Gynecol Surv 2019; 73:587-594. [PMID: 30379320 DOI: 10.1097/ogx.0000000000000597] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Importance Postpartum hemorrhage (PPH) remains a major cause of maternal mortality worldwide, occurring in both vaginal and cesarean deliveries. We have witnessed improvements in both prevention and treatment of PPH. Tranexamic acid (TXA) has been investigated as a potential adjunct therapy to uterotonics within this setting. Objective The aim of this article is to summarize existing recommendations on the use of TXA in obstetrics and review current data on clinical outcomes after TXA use. Evidence Acquisition We reviewed guidelines from a number of professional societies and performed an extensive literature search reviewing relevant and current data in this area. Results and Conclusions In the prevention of PPH, TXA use before both vaginal and cesarean deliveries reduces the amount of postpartum blood loss and should be considered in patients at higher risk for hemorrhage. In the treatment of PPH, TXA should be initiated early for maximal survival benefit from hemorrhage, and it provides no additional benefit if administered more than 3 hours from delivery. Overall, current evidence assessing the risks of TXA use in an obstetric population is reassuring.
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Abdelaleem AA, Abbas AM, Thabet AL, Badran E, El-Nashar IH. The effect of initiating intravenous oxytocin infusion before uterine incision on the blood loss during elective cesarean section: a randomized clinical trial. J Matern Fetal Neonatal Med 2018; 32:3723-3728. [PMID: 29712515 DOI: 10.1080/14767058.2018.1471461] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Objective: This study compares the effect of starting intravenous oxytocin infusion early before uterine incision versus late after umbilical cord clamping on the blood loss during elective cesarean section (CS). Methods: A single-blinded randomized clinical trial conducted on 200 pregnant women at term (>37 weeks) gestation scheduled for elective CS were assigned to either IV infusion of 30 IU of oxytocin started before uterine incision (Group I) or started immediately after clamping the umbilical cord (Group II). The primary outcome was the mean volume of blood loss during CS. The secondary outcomes included the mean volume of postoperative blood loss, the mean reduction in the hemoglobin and hematocrit levels, the need for additional uterotonics, blood transfusion and additional surgical procedures. Results: The baseline characteristics of both groups are quiet similar. No statistical significant difference between both groups as regard to pre- and postpartum hemoglobin levels (p = .06 and 0.24 respectively) and hematocrit values (p = .12 and .51 respectively). There was a significant reduction in the intraoperative blood loss in group I compared with group II (432.7 ± 90.6 versus 588.9 ± 96.3 mL respectively, p = .001). The need for additional uterotonics was more frequent in the group II (19 women) than in group I (seven women) with statistical significance (p = .002). No differences between both groups regarding the need for blood transfusion or additional surgical procedures. Conclusions: Initiating intravenous oxytocin infusion before uterine incision during elective CS could be associated with reduction in the intraoperative blood loss and the need for additional uterotonics.
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Affiliation(s)
- Ahmed A Abdelaleem
- a Department of Obstetrics & Gynecology, Faculty of Medicine , Assiut University , Assiut , Egypt
| | - Ahmed M Abbas
- a Department of Obstetrics & Gynecology, Faculty of Medicine , Assiut University , Assiut , Egypt
| | - Andrew L Thabet
- a Department of Obstetrics & Gynecology, Faculty of Medicine , Assiut University , Assiut , Egypt
| | - Esraa Badran
- a Department of Obstetrics & Gynecology, Faculty of Medicine , Assiut University , Assiut , Egypt
| | - Ihab H El-Nashar
- a Department of Obstetrics & Gynecology, Faculty of Medicine , Assiut University , Assiut , Egypt
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Pabinger I, Fries D, Schöchl H, Streif W, Toller W. Tranexamic acid for treatment and prophylaxis of bleeding and hyperfibrinolysis. Wien Klin Wochenschr 2017; 129:303-316. [PMID: 28432428 PMCID: PMC5429347 DOI: 10.1007/s00508-017-1194-y] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 03/14/2017] [Indexed: 02/08/2023]
Abstract
Uncontrolled massive bleeding with subsequent derangement of the coagulation system is a major challenge in the management of both surgical and seriously injured patients. Under physiological conditions activators and inhibitors of coagulation regulate the sensitive balance between clot formation and fibrinolysis. In some cases, excessive and diffuse bleeding is caused by systemic activation of fibrinolysis, i. e. hyperfibrinolysis (HF). Uncontrolled HF is associated with a high mortality. Polytrauma patients and those undergoing surgical procedures involving organs rich in plasminogen proactivators (e. g. liver, kidney, pancreas, uterus and prostate gland) are at a high risk for HF. Antifibrinolytics, such as tranexamic acid (TXA) are used for prophylaxis and treatment of bleeding caused by a local or generalized HF as well as other hemorrhagic conditions. TXA is a synthetic lysine analogue that has been available in Austria since 1966. TXA is of utmost importance in the prevention and treatment of traumatic and perioperative bleeding due to the resulting reduction in perioperative blood loss and blood transfusion requirements. The following article presents the different fields of application of TXA with particular respect to indications and dosages, based on a literature search and on current guidelines.
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Affiliation(s)
- Ingrid Pabinger
- Clinical Department of Hematology and Hemostaseology, Medical University Vienna, Vienna, Austria.
| | - Dietmar Fries
- Department of General and Surgical Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Herbert Schöchl
- Department of Anesthesiology and Intensive Care Medicine, AUVA Accident Hospital Salzburg, Salzburg, Austria
- Academic Teaching Hospital, Paracelsus Private Medical University Salzburg, Salzburg, Austria
| | - Werner Streif
- Department of Children and Adolescents Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Wolfgang Toller
- Department of Anesthesiology and Intensive Care Medicine, Medical University Graz, Graz, Austria
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Lakshmi SJD, Abraham R. Role of Prophylactic Tranexamic Acid in Reducing Blood Loss during Elective Caesarean Section: A Randomized Controlled Study. J Clin Diagn Res 2016; 10:QC17-QC21. [PMID: 28208943 PMCID: PMC5296516 DOI: 10.7860/jcdr/2016/21702.9050] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 09/30/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Obstetric haemorrhage accounts for 20-25% of maternal mortality and morbidity. Anti-fibrinolytics are being widely used in field of surgery. It is also used to reduce heavy menstrual blood loss. AIM To analyse the effectiveness of Tranexamic Acid (TXA) in reducing blood loss during elective caesarean section. MATERIALS AND METHODS This interventional, randomized, parallel group study was done in the Department of Obstetrics and Gynaecolgy, PSG IMSR, Coimbatore, from June 2014 to May 2015. It was conducted on 120 women undergoing caesarean section. They were allocated to either Study or Control group by computer generated random number tables. TXA was given prior to surgery in study group in addition to the routine care {10 units of oxytocin added to the intravenous drip soon after baby delivery} whereas, the control group had routine care alone. Blood loss was measured in both groups by gravimetric method. Haemoglobin before and after surgery was estimated and the percentage of difference was compared. STATISTICAL ANALYSIS Primary outcome variables were volume of blood loss and percentage fall in haemoglobin before and after surgery. Secondary outcomes were duration of surgery, proportion of subjects with >500ml of blood loss, need for additional uterotonics and side effects. Unpaired t-test and Chi-square test were used to compare the outcome variables. RESULTS There was significant reduction in blood loss calculated from placental delivery till end of surgery: 347.17ml in study group versus 517.72ml in control group (p<0.001). Another parameter studied was the percentage of fall in haemoglobin before and after surgery and the number of subjects who had more than 10% fall in haemoglobin. 9.3% of subjects in study group and 39% of subjects in control group had more than 10% fall in haemoglobin (p<0.01). There were no immediate post-operative complications to the mother and neonate. CONCLUSION TXA significantly reduced the amount of blood loss during Lower Segment Caesarean Section (LSCS). Use of TXA was not associated with adverse effects. Thus, TXA can be used safely and effectively in subjects undergoing LSCS.
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Affiliation(s)
- SJ Dhivya Lakshmi
- Junior Resident, Department of Obstetrics and Gynecology, Peelamedu Samanaidu Govindasaminaidu Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Reena Abraham
- Professor, Department of Obstetrics and Gynecology, Peelamedu Samanaidu Govindasaminaidu Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
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Sentilhes L, Brun S, Madar H, Deneux-Tharaux C. Tranexamic Acid for Prevention PPH: a Promising Drug But Today Only a Promising Drug. Transfus Med Rev 2016; 30:100. [DOI: 10.1016/j.tmrv.2016.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 01/13/2016] [Accepted: 01/28/2016] [Indexed: 10/22/2022]
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Wang H, Hong S, Teng H, Qiao L, Yin H. Subcuticular sutures versus staples for skin closure after cesarean delivery: a meta-analysis. J Matern Fetal Neonatal Med 2016; 29:3705-11. [PMID: 26785886 DOI: 10.3109/14767058.2016.1141886] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To compare the clinical efficacy between subcuticular sutures and staples for skin closure after cesarean delivery. METHODS PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and Web of Science were searched. Only RCTs comparing subcuticular sutures to staples following cesarean delivery were included. The primary outcome was the incidence of wound complications, consisting of wound infection, wound separation, hematoma and seroma. Risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI) was calculated. RESULTS Ten RCTs were included in this analysis. Subcuticular sutures were associated with significantly decreased incidence of wound complications compared to staples (RR 1.88, 95% CI 1.45-2.45). The operation time was significantly shortened when closure with staples was performed (MD -8.66 min, 95% CI -10.90 to -6.42). The two groups were comparable regarding cosmetic outcome at 6-8 weeks postoperatively, whereas subcuticular sutures were associated with a better cosmesis at 6-12 months postoperatively. There were no significant differences between groups in terms of hospital stay, postoperative pain and patient satisfaction. CONCLUSIONS Compared with staples following cesarean delivery, subcuticular sutures are associated with decreased risk of wound complications and better long-term cosmetic outcome, but slightly prolong duration of surgery.
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Affiliation(s)
- Hongye Wang
- a Department of Obstetrics and Gynecology and
| | - Shukun Hong
- b Department of Intensive Care Unit , Shengli Oilfield Central Hospital , Dongying , PR China
| | | | - Lujun Qiao
- b Department of Intensive Care Unit , Shengli Oilfield Central Hospital , Dongying , PR China
| | - Hongmei Yin
- a Department of Obstetrics and Gynecology and
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