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Zhang P, Jia YJ, Lv Y, Fan YF, Geng H, Zhao Y, Song H, Cui HY, Chen X. Effects of tranexamic acid preconditioning on the incidence of postpartum haemorrhage in vaginal deliveries with identified risk factors in China: a prospective, randomized, open-label, blinded endpoint trial. Ann Med 2024; 56:2389302. [PMID: 39129492 PMCID: PMC11321115 DOI: 10.1080/07853890.2024.2389302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 05/02/2024] [Accepted: 07/05/2024] [Indexed: 08/13/2024] Open
Abstract
OBJECTIVE This study aimed to evaluate the effects of tranexamic acid (TXA) in preventing postpartum haemorrhage (PPH) among women with identified risk factors for PPH undergoing vaginal delivery in China. METHODS This prospective, randomized, open-label, blinded endpoint (PROBE) trial enrolled 2258 women with one or more risk factors for PPH who underwent vaginal delivery. Participants were randomly assigned in a 1:1 ratio to receive an intravascular infusion of 1 g TXA or a placebo immediately after the delivery of the infant. The primary outcome assessed was the incidence of PPH, defined as blood loss ≥500 mL within 24 h after delivery, while severe PPH was considered as a secondary outcome and defined by total blood loss ≥1000 mL within 24 h. RESULTS 2245 individuals (99.4%) could be followed up to their primary outcome. PPH occurred in 186 of 1128 women in the TXA group and in 215 of 1117 women in the placebo group (16.5% vs. 19.2%; RR, 0.86; 95% CI, 0.72 to 1.02; p = 0.088). Regarding secondary outcomes related to efficacy, women in the TXA group had a significant lower rate of severe PPH than those in the placebo group (2.7% vs. 5.6%; RR, 0.49; 95% CI, 0.32 to 0.74; p = 0.001; adjusted p = 0.002). Similarly, there was a significant reduction in the use of additional uterotonic agents (7.8% vs. 15.6%; RR, 0.50; 95% CI, 0.39 to 0.63; p < 0.001; adjusted p = 0.001). No occurrence of thromboembolic events and maternal deaths were reported in both groups within 30 days after delivery. CONCLUSIONS In total population with risk factors for PPH, the administration of TXA following vaginal delivery did not result in a statistically significant reduction in the incidence of PPH compared to placebo; however, it was associated with a significantly lower incidence of severe PPH.
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Affiliation(s)
- Pei Zhang
- School of Medicine, Nankai University, Tianjin, China
- Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, China
- Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin, China
| | - Yan-Ju Jia
- Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, China
| | - Yan Lv
- Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, China
| | - Yi-Fan Fan
- School of Medicine, Nankai University, Tianjin, China
- Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, China
- Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin, China
| | - Hao Geng
- School of Medicine, Nankai University, Tianjin, China
- Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, China
- Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin, China
| | - Ying Zhao
- School of Medicine, Nankai University, Tianjin, China
- Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, China
- Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin, China
| | - Hui Song
- School of Medicine, Nankai University, Tianjin, China
- Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, China
- Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin, China
| | - Hong-Yan Cui
- School of Medicine, Nankai University, Tianjin, China
- Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, China
| | - Xu Chen
- School of Medicine, Nankai University, Tianjin, China
- Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, China
- Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin, China
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Karanicolas PJ, Lin Y, McCluskey SA, Tarshis J, Thorpe KE, Wei A, Dixon E, Porter G, Chaudhury P, Nanji S, Ruo L, Tsang ME, Skaro A, Eeson G, Cleary S, Moulton CA, Ball CG, Hallet J, Coburn N, Serrano PE, Jayaraman S, Law C, Tandan V, Sapisochin G, Nagorney D, Quan D, Smoot R, Gallinger S, Metrakos P, Reichman TW, Jalink D, Bennett S, Sutherland F, Solano E, Molinari M, Tang ES, Warner SG, Bathe OF, Barkun J, Kendrick ML, Truty M, Roke R, Xu G, Lafreniere-Roula M, Guyatt G. Tranexamic Acid in Patients Undergoing Liver Resection: The HeLiX Randomized Clinical Trial. JAMA 2024:2822555. [PMID: 39158894 PMCID: PMC11334013 DOI: 10.1001/jama.2024.11783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 05/30/2024] [Indexed: 08/20/2024]
Abstract
Importance Tranexamic acid reduces bleeding and blood transfusion in many types of surgery, but its effect in patients undergoing liver resection for a cancer-related indication remains unclear. Objective To determine whether tranexamic acid reduces red blood cell transfusion within 7 days of liver resection. Design, Setting, and Participants Multicenter randomized clinical trial of tranexamic acid vs placebo conducted from December 1, 2014, to November 8, 2022, at 10 hepatopancreaticobiliary sites in Canada and 1 site in the United States, with 90-day follow-up. Participants, clinicians, and data collectors were blinded to allocation. A volunteer sample of 1384 patients undergoing liver resection for a cancer-related indication met eligibility criteria and consented to randomization. Interventions Tranexamic acid (1-g bolus followed by 1-g infusion over 8 hours; n = 619) or matching placebo (n = 626) beginning at induction of anesthesia. Main Outcomes and Measures The primary outcome was receipt of red blood cell transfusion within 7 days of surgery. Results The primary analysis included 1245 participants (mean age, 63.2 years; 39.8% female; 56.1% with a diagnosis of colorectal liver metastases). Perioperative characteristics were similar between groups. Red blood cell transfusion occurred in 16.3% of participants (n = 101) in the tranexamic acid group and 14.5% (n = 91) in the placebo group (odds ratio, 1.15 [95% CI, 0.84-1.56]; P = .38; absolute difference, 2% [95% CI, -2% to 6%]). Measured intraoperative blood loss (tranexamic acid, 817.3 mL; placebo, 836.7 mL; P = .75) and total estimated blood loss over 7 days (tranexamic acid, 1504.0 mL; placebo, 1551.2 mL; P = .38) were similar between groups. Participants receiving tranexamic acid experienced significantly more complications compared with placebo (odds ratio, 1.28 [95% CI, 1.02-1.60]; P = .03), with no significant difference in venous thromboembolism (odds ratio, 1.68 [95% CI, 0.95-3.07]; P = .08). Conclusions and Relevance Among patients undergoing liver resection for a cancer-related indication, tranexamic acid did not reduce bleeding or blood transfusion but increased perioperative complications. Trial Registration ClinicalTrials.gov Identifier: NCT02261415.
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Affiliation(s)
- Paul J. Karanicolas
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Yulia Lin
- Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Stuart A. McCluskey
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jordan Tarshis
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kevin E. Thorpe
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Alice Wei
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Elijah Dixon
- Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Geoff Porter
- Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Prosanto Chaudhury
- McGill University Health Centre, Montreal, Quebec, Canada
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Sulaiman Nanji
- Department of Surgery, Queen’s University, Kingston, Ontario, Canada
- Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Leyo Ruo
- Juravinski Hospital, Hamilton, Ontario, Canada
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Melanie E. Tsang
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, Unity Health Toronto–St Joseph’s Health Centre, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
| | - Anton Skaro
- London Health Sciences Centre, London, Ontario, Canada
- Department of Surgery, Western University, London, Ontario, Canada
| | - Gareth Eeson
- Kelowna General Hospital, Kelowna, British Columbia, Canada
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sean Cleary
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Carol-Anne Moulton
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Chad G. Ball
- Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Julie Hallet
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Natalie Coburn
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Pablo E. Serrano
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Surgery, Juravinski Hospital, Hamilton, Ontario, Canada
| | - Shiva Jayaraman
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, Unity Health Toronto–St Joseph’s Health Centre, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
| | - Calvin Law
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Ved Tandan
- Juravinski Hospital, Hamilton, Ontario, Canada
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Gonzalo Sapisochin
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - David Nagorney
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Douglas Quan
- London Health Sciences Centre, London, Ontario, Canada
- Department of Surgery, Western University, London, Ontario, Canada
| | - Rory Smoot
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Steven Gallinger
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Peter Metrakos
- McGill University Health Centre, Montreal, Quebec, Canada
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Trevor W. Reichman
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Diederick Jalink
- Department of Surgery, Queen’s University, Kingston, Ontario, Canada
- Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Sean Bennett
- Department of Surgery, Queen’s University, Kingston, Ontario, Canada
- Department of Surgery, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Francis Sutherland
- Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Edward Solano
- Kelowna General Hospital, Kelowna, British Columbia, Canada
| | - Michele Molinari
- Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ephraim S. Tang
- London Health Sciences Centre, London, Ontario, Canada
- Department of Surgery, Western University, London, Ontario, Canada
| | | | - Oliver F. Bathe
- Department of Surgery and Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Jeffrey Barkun
- McGill University Health Centre, Montreal, Quebec, Canada
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | | | - Mark Truty
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Rachel Roke
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Grace Xu
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Poston JN, Andrews J, Arya S, Chou ST, Cohn C, Covington M, Crowe EP, Goel R, Gupta GK, Haspel RL, Hess A, Ipe TS, Jacobson J, Khan J, Murphy M, O'Brien K, Pagano MB, Panigrahi AK, Salazar E, Saifee NH, Stolla M, Zantek ND, Ziman A, Metcalf RA. Current advances in 2024: A critical review of selected topics by the Association for the Advancement of Blood and Biotherapies (AABB) Clinical Transfusion Medicine Committee. Transfusion 2024. [PMID: 39087455 DOI: 10.1111/trf.17975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Accepted: 07/14/2024] [Indexed: 08/02/2024]
Affiliation(s)
- Jacqueline N Poston
- Department of Pathology and Laboratory Medicine, University of Vermont, Burlington, Vermont, USA
- Department of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Jennifer Andrews
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Stella T Chou
- Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Claudia Cohn
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mischa Covington
- Transfusion Medicine, Harvard University, Boston, Massachusetts, USA
| | - Elizabeth P Crowe
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ruchika Goel
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Internal Medicine, Southern Illinois University, Springfield, Illinois, USA
| | - Gaurav K Gupta
- Transfusion Medicine and Cellular therapy, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Richard L Haspel
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Aaron Hess
- Departments of Anesthesiology and Pathology & Laboratory Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Tina S Ipe
- Center for Apheresis and Regenerative Medicine, Little Rock, Arkansas, USA
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jessica Jacobson
- Department of Pathology, NYU Grossman School of Medicine, New York, New York, USA
| | - Jenna Khan
- Department of Pathology, University of Virginia, Charlottesville, Virginia, USA
| | - Mike Murphy
- NHS Blood and Transplant, Oxford University Hospitals NHS Foundation Trust, and the University of Oxford, Oxford, UK
| | - Kerry O'Brien
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Monica B Pagano
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Anil K Panigrahi
- Departments of Anesthesiology and Pathology, Stanford University, Stanford, California, USA
| | - Eric Salazar
- Department of Pathology and Laboratory Medicine, UT Health San Antonio, San Antonio, Texas, USA
| | - Nabiha H Saifee
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
- Seattle Children's Hospital, Seattle, Washington, USA
| | - Moritz Stolla
- Bloodworks Northwest Research Institute, Seattle, Washington, USA
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Alyssa Ziman
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Ryan A Metcalf
- Department of Pathology, University of Utah, Salt Lake City, Utah, USA
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Whitley J, Miran SA, Ma P, Saade G, Roberts I, Ahmadzia HK. When Are Pregnant Patients Receiving Tranexamic Acid during Delivery Hospitalization in the United States? Am J Perinatol 2024. [PMID: 38925162 DOI: 10.1055/a-2353-0832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
OBJECTIVE The World Health Organization recommends tranexamic acid (TXA) in the management of postpartum hemorrhage (PPH). However, the role of TXA in PPH prevention and the optimal timing of TXA administration remain unknown. Our objective was to describe the timing of TXA administration, differences in timing of TXA administration by mode of delivery, and current trends in TXA administration in the United States. STUDY DESIGN We conducted a descriptive study of trends in TXA administration using the Cerner Real-World Database. We identified 1,544,712 deliveries occurring at greater than 24 weeks' gestation from January 1, 2016, to February 21, 2023. Demographic data were collected including gestational age, mode of delivery, and comorbidities. The timing of TXA administration and differences in TXA timing by mode of delivery were also collected. RESULTS In our cohort, 21,433 patients (1.39%) received TXA. The majority of patients who received TXA were between ages 25 and 34 years old (55.3%), White (60.7%), and delivered between 37 and 416/7 weeks (81.4%). The TXA group had a higher prevalence of medical comorbidities including obesity (32.9 vs. 19.0%, p < 0.00001), preeclampsia (19.6 vs. 6.81%, p < 0.00001), and pregestational diabetes (3.27 vs. 1.36%, p < 0.00001). Among women who received TXA, 15.4% received it within 3 hours before delivery. Among patients who received TXA after delivery, 23.6% received TXA within 3 hours after delivery, whereas 35.7% received TXA between 10 and 24 hours after delivery. A total of 80.4% of patients who received TXA before delivery had a cesarean delivery. CONCLUSION While TXA is most commonly administered after delivery, many patients are receiving TXA prior to delivery in the United States without clear evidence to guide the timing of administration. A randomized trial is urgently needed to determine the safety and efficacy of TXA when administered prior to delivery. KEY POINTS · TXA is used in the treatment of PPH.. · The role of TXA in prevention of PPH is unclear.. · Fewer than 2% of patients in the United States receive TXA at delivery.. · TXA administration before delivery in the United States is rising..
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Affiliation(s)
- Julia Whitley
- Division of Maternal-Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Seyedeh A Miran
- Department of Clinical Research and Leadership, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Phillip Ma
- Department of Clinical Research and Leadership, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - George Saade
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Homa K Ahmadzia
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Inova Health System, Falls Church, Virginia
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Wang M, Yi G, Zhang Y, Li M, Zhang J. Quantitative prediction of postpartum hemorrhage in cesarean section on machine learning. BMC Med Inform Decis Mak 2024; 24:166. [PMID: 38872184 DOI: 10.1186/s12911-024-02571-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 06/10/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND Cesarean section-induced postpartum hemorrhage (PPH) potentially causes anemia and hypovolemic shock in pregnant women. Hence, it is helpful for obstetricians and anesthesiologists to prepare pre-emptive prevention when predicting PPH occurrence in advance. However, current works on PPH prediction focus on whether PPH occurs rather than assessing PPH amount. To this end, this work studies quantitative PPH prediction with machine learning (ML). METHODS The study cohort in this paper was selected from individuals with PPH who were hospitalized at Shijiazhuang Obstetrics and Gynecology Hospital from 2020 to 2022. In this study cohort, we built a dataset with 6,144 subjects covering clinical parameters, anesthesia operation records, laboratory examination results, and other information in the electronic medical record system. Based on our built dataset, we exploit six different ML models, including logistic regression, linear regression, gradient boosting, XGBoost, multilayer perceptron, and random forest, to automatically predict the amount of bleeding during cesarean section. Eighty percent of the dataset was used as model training, and 20 % was used for verification. Those ML models are constantly verified and improved by root mean squared error(RMSE) and mean absolute error(MAE). Moreover, we also leverage the importance of permutation and partial dependence plot (PDP) to discuss their feasibility. RESULT The experiment results show that random forest obtains the highest accuracy for PPH amount prediction compared to other ML methods. Random forest reaches the mean absolute error of 21.7, less than 5.4 % prediction error. It also gains the root mean squared error of 33.75, less than 9.3 % prediction error. On the other hand, the experimental results also disclose indicators that contributed most to PPH prediction, including Ca, hemoglobin, white blood cells, platelets, Na, and K. CONCLUSION It effectively predicts the amount of PPH during a cesarean section by ML methods, especially random forest. With the above insight, ML predicting PPH amounts provides early warning for clinicians, thus reducing complications and improving cesarean sections' safety. Furthermore, the importance of ML and permutation, complemented by incorporating PDP, promises to provide clinicians with a transparent indication of individual risk prediction.
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Affiliation(s)
- Meng Wang
- School of Information Engineering, China University of Geosciences, Beijing, 100083, China
- Tangshan Polytechnic College, Tangshan, 063299, China
| | - Gao Yi
- Shijiazhuang Obstetrics and Gynecology Hospital, Shijiazhuang, 050000, China
| | - Yunjia Zhang
- School of Information Engineering, China University of Geosciences, Beijing, 100083, China
| | - Mei Li
- School of Information Engineering, China University of Geosciences, Beijing, 100083, China.
| | - Jin Zhang
- Shijiazhuang Obstetrics and Gynecology Hospital, Shijiazhuang, 050000, China.
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Ács N, Korte WC, von Heymann CC, Windyga J, Blatný J. Rationale for the Potential Use of Recombinant Activated Factor VII in Severe Post-Partum Hemorrhage. J Clin Med 2024; 13:2928. [PMID: 38792469 PMCID: PMC11122570 DOI: 10.3390/jcm13102928] [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: 02/28/2024] [Revised: 04/17/2024] [Accepted: 04/25/2024] [Indexed: 05/26/2024] Open
Abstract
Severe post-partum hemorrhage (PPH) is a major cause of maternal mortality worldwide. Recombinant activated factor VII (rFVIIa) has recently been approved by the European Medicines Agency for the treatment of severe PPH if uterotonics fail to achieve hemostasis. Although large randomized controlled trials are lacking, accumulated evidence from smaller studies and international registries supports the efficacy of rFVIIa alongside extended standard treatment to control severe PPH. Because rFVIIa neither substitutes the activity of a missing coagulation factor nor bypasses a coagulation defect in this population, it is not immediately evident how it exerts its beneficial effect. Here, we discuss possible mechanistic explanations for the efficacy of rFVIIa and the published evidence in patients with severe PPH. Recombinant FVIIa may not primarily increase systemic thrombin generation, but may promote local thrombin generation through binding to activated platelets at the site of vascular wall injury. This explanation may also address safety concerns that have been raised over the administration of a procoagulant molecule in a background of increased thromboembolic risk due to both pregnancy-related hemostatic changes and the hemorrhagic state. However, the available safety data for this and other indications are reassuring and the rates of thromboembolic events do not appear to be increased in women with severe PPH treated with rFVIIa. We recommend that the administration of rFVIIa be considered before dilutional coagulopathy develops and used to support the current standard treatment in certain patients with severe PPH.
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Affiliation(s)
- Nándor Ács
- Department of Obstetrics and Gynaecology, Semmelweis University, H-1082 Budapest, Hungary
| | - Wolfgang C. Korte
- Centre for Laboratory Medicine, Haemostasis and Haemophilia Centre, CH-9001 St. Gallen, Switzerland
| | - Christian C. von Heymann
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum in Friedrichshain, DE-10249 Berlin, Germany
| | - Jerzy Windyga
- Department of Haemostasis Disorders and Internal Medicine, Laboratory of Haemostasis and Metabolic Diseases, Institute of Haematology and Transfusion Medicine, 02-776 Warsaw, Poland
| | - Jan Blatný
- Department of Paediatric Oncology, University Hospital Brno, and Masaryk University, 613 00 Brno, Czech Republic
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Bruno AM, Federspiel JJ, McGee P, Pacheco LD, Saade GR, Parry S, Longo M, Tita ATN, Gyamfi-Bannerman C, Chauhan SP, Einerson BD, Rood K, Rouse DJ, Bailit J, Grobman WA, Simhan HN. Validation of Three Models for Prediction of Blood Transfusion during Cesarean Delivery Admission. Am J Perinatol 2024; 41:e3391-e3400. [PMID: 38134939 PMCID: PMC11153014 DOI: 10.1055/a-2234-8171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
OBJECTIVE Prediction of blood transfusion during delivery admission allows for clinical preparedness and risk mitigation. Although prediction models have been developed and adopted into practice, their external validation is limited. We aimed to evaluate the performance of three blood transfusion prediction models in a U.S. cohort of individuals undergoing cesarean delivery. STUDY DESIGN This was a secondary analysis of a multicenter randomized trial of tranexamic acid for prevention of hemorrhage at time of cesarean delivery. Three models were considered: a categorical risk tool (California Maternal Quality Care Collaborative [CMQCC]) and two regression models (Ahmadzia et al and Albright et al). The primary outcome was intrapartum or postpartum red blood cell transfusion. The CMQCC algorithm was applied to the cohort with frequency of risk category (low, medium, high) and associated transfusion rates reported. For the regression models, the area under the receiver-operating curve (AUC) was calculated and a calibration curve plotted to evaluate each model's capacity to predict receipt of transfusion. The regression model outputs were statistically compared. RESULTS Of 10,785 analyzed individuals, 3.9% received a red blood cell transfusion during delivery admission. The CMQCC risk tool categorized 1,970 (18.3%) individuals as low risk, 5,259 (48.8%) as medium risk, and 3,556 (33.0%) as high risk with corresponding transfusion rates of 2.1% (95% confidence interval [CI]: 1.5-2.9%), 2.2% (95% CI: 1.8-2.6%), and 7.5% (95% CI: 6.6-8.4%), respectively. The AUC for prediction of blood transfusion using the Ahmadzia and Albright models was 0.78 (95% CI: 0.76-0.81) and 0.79 (95% CI: 0.77-0.82), respectively (p = 0.38 for difference). Calibration curves demonstrated overall agreement between the predicted probability and observed likelihood of blood transfusion. CONCLUSION Three models were externally validated for prediction of blood transfusion during cesarean delivery admission in this U.S. COHORT Overall, performance was moderate; model selection should be based on ease of application until a specific model with superior predictive ability is developed. KEY POINTS · A total of 3.9% of individuals received a blood transfusion during cesarean delivery admission.. · Three models used in clinical practice are externally valid for blood transfusion prediction.. · Institutional model selection should be based on ease of application until further research identifies the optimal approach..
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Affiliation(s)
- Ann M Bruno
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Jerome J Federspiel
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina
| | - Paula McGee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The George Washington University Biostatistics Center, Washington, District of Columbia
| | - Luis D Pacheco
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas
| | - George R Saade
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas
| | - Samuel Parry
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Monica Longo
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Alan T N Tita
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Cynthia Gyamfi-Bannerman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - Suneet P Chauhan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston, Children's Memorial Hermann Hospital, Houston, Texas
| | - Brett D Einerson
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Kara Rood
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
| | - Dwight J Rouse
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island
| | - Jennifer Bailit
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The MetroHealth Medical System, Case Western Reserve University, Cleveland, Ohio
| | - William A Grobman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Hyagriv N Simhan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania
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8
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Lee A, Wang MYF, Roy D, Wang J, Gokhale A, Miranda-Cacdac L, Kuntz M, Grover B, Gray K, Curley KL. Prophylactic Tranexamic Acid Prevents Postpartum Hemorrhage and Transfusions in Cesarean Deliveries: A Systematic Review and Meta-analysis. Am J Perinatol 2024; 41:e2254-e2268. [PMID: 37311543 DOI: 10.1055/a-2109-3730] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide and PPH resulting in transfusion is the most common maternal morbidity in the United States. Literature demonstrates that tranexamic acid (TXA) can reduce blood loss in cesarean deliveries; however, there is little consensus on the impact on major morbidities like PPH and transfusions. We conducted a systematic review/meta-analysis of randomized controlled trials (RCTs) to evaluate if administration of prophylactic intravenous (IV) TXA prevents PPH and/or transfusions following low-risk cesarean delivery. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines were followed. Five databases were searched: Cochrane, EBSCO, Ovid, PubMed, and ClinicalKey. RCTs published in English between January 2000 and December 2021 were included. Studies compared PPH and transfusions in cesarean deliveries between prophylactic IV TXA and control (placebo or no placebo). The primary outcome was PPH, and the secondary outcome was transfusions. Random effects models were used to calculate effect size (ES) of exposure in Mantel-Haenszel risk ratios (RR). All analysis was done at a confidence level (CI) of α = 0.5. Modeling showed that TXA led to significantly less risk of PPH than control (RR: 0.43; 95% CI: 0.28-0.67). The effect on transfusion was comparable (RR: 0.39; 95% CI: 0.21-0.73). Heterogeneity was minimal (I 2 = 0%). Due to the large sample sizes needed, many RCTs are not powered to interpret TXA's effect on PPH and transfusions. Pooling these studies in a meta-analysis allows for more power and analysis but is limited by the heterogeneity of studies. Our results minimize heterogeneity while demonstrating that prophylactic TXA can lower PPH occurrence and reduce the need for blood transfusion. We suggest considering prophylactic IV TXA as the standard of care in low-risk cesarean deliveries. KEY POINTS: · Consider TXA prior to incision for singleton, term pregnancies undergoing elective cesarean.. · Prophylactic TXA is effective in preventing PPH and blood transfusions.. · Routine use of TXA has the potential to decrease transfusion-related complications and costs..
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Affiliation(s)
- Amy Lee
- A.T. Still University School of Osteopathic Medicine in Arizona, Mesa, Arizona
| | - Mary Ying-Fang Wang
- A.T. Still University School of Osteopathic Medicine in Arizona, Mesa, Arizona
| | - Debosree Roy
- A.T. Still University School of Osteopathic Medicine in Arizona, Mesa, Arizona
| | - Jenny Wang
- A.T. Still University School of Osteopathic Medicine in Arizona, Mesa, Arizona
| | - Abha Gokhale
- A.T. Still University School of Osteopathic Medicine in Arizona, Mesa, Arizona
| | | | - Moriah Kuntz
- A.T. Still University School of Osteopathic Medicine in Arizona, Mesa, Arizona
| | - Bryan Grover
- Department of Obstetrics and Gynecology, Banner University Medical Center Phoenix, Phoenix, Arizona
| | - Kendra Gray
- Department of Obstetrics and Gynecology, Banner University Medical Center Phoenix, Phoenix, Arizona
| | - Kathleen L Curley
- Department of Obstetrics and Gynecology, Banner University Medical Center Phoenix, Phoenix, Arizona
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9
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Mackeen AD, Sullivan MV, Berghella V. Evidence-based cesarean delivery: preoperative management (part 7). Am J Obstet Gynecol MFM 2024; 6:101362. [PMID: 38574855 DOI: 10.1016/j.ajogmf.2024.101362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/18/2024] [Accepted: 03/28/2024] [Indexed: 04/06/2024]
Abstract
Preoperative preparation for cesarean delivery is a multistep approach for which protocols should exist at each hospital system. These protocols should be guided by the findings of this review. The interventions reviewed and recommendations made for this review have a common goal of decreasing maternal and neonatal morbidity and mortality related to cesarean delivery. The preoperative period starts before the patient's arrival to the hospital and ends immediately before skin incision. The Centers for Disease Control and Prevention recommends showering with either soap or an antiseptic solution at least the night before a procedure. Skin cleansing in addition to this has not been shown to further decrease rates of infection. Hair removal at the cesarean skin incision site is not necessary, but if preferred by the surgical team then clipping or depilatory creams should be used rather than shaving. Preoperative enema is not recommended. A clear liquid diet may be ingested up to 2 hours before and a light meal up to 6 hours before cesarean delivery. Consider giving a preoperative carbohydrate drink to nondiabetic patients up to 2 hours before planned cesarean delivery. Weight-based intravenous cefazolin is recommended 60 minutes before skin incision: 1-2 g intravenous for patients without obesity and 2 g for patients with obesity or weight ≥80 kg. Adjunctive azithromycin 500 mg intravenous is recommended for patients with labor or rupture of membranes. Preoperative gabapentin can be considered as a way to decrease pain scores with movement in the postoperative period. Tranexamic acid (1 g in 10-20 mL of saline or 10 mg/kg intravenous) is recommended prophylactically for patients at high risk of postpartum hemorrhage and can be considered in all patients. Routine use of mechanical venous thromboembolism prophylaxis is recommended preoperatively and is to be continued until the patient is ambulatory. Music and active warming of the patient, and adequate operating room temperature improves outcomes for the patient and neonate, respectively. Noise levels should allow clear communication between teams; however, a specific decibel level has not been defined in the data. Patient positioning with left lateral tilt decreases hypotensive episodes compared with right lateral tilt, which is not recommended. Manual displacers result in fewer hypotensive episodes than left lateral tilt. Both vaginal and skin preparation should be performed with either chlorhexidine (preferred) or povidone iodine. Placement of an indwelling urinary catheter is not necessary. Nonadhesive drapes are recommended. Cell salvage, although effective for high-risk patients, is not recommended for routine use. Maternal supplemental oxygen does not improve outcomes. A surgical safety checklist (including a timeout) is recommended for all cesarean deliveries.
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Affiliation(s)
- A Dhanya Mackeen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Geisinger, Danville, PA (Drs Mackeen and Sullivan).
| | - Maranda V Sullivan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Geisinger, Danville, PA (Drs Mackeen and Sullivan)
| | - Vincenzo Berghella
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA (Dr Berghella)
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10
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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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11
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Verspyck E, Morau E, Chiesa-Dubruille C, Bonnin M. [Maternal mortality due to obstetric haemorrhage in France 2016-2018]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2024; 52:238-245. [PMID: 38373487 DOI: 10.1016/j.gofs.2024.02.016] [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: 02/10/2024] [Accepted: 02/10/2024] [Indexed: 02/21/2024]
Abstract
Between 2016 and 2018, 20 maternal deaths were related to obstetric haemorrhage, excluding haemorrhage in the first trimester of pregnancy, representing a mortality ratio of 0.87 per 100,000 live births (95% CI 0.5 -1.3). Obstetric haemorrhage is the cause of 7.4% of all maternal deaths up to 1 year, 10% of maternal deaths within 42days, and 21% of deaths directly related to pregnancy (direct causes). Between 2001 and 2018, maternal mortality from obstetric haemorrhage has been considerably reduced, from 2.2deaths per 100,000 live births in 2001-2003 to 0.87 in the period presented here. Nevertheless, obstetric haemorrhage is still one of the main direct causes of maternal death, and remains the cause with the highest proportion of deaths considered probably (53%) or possibly (42%) preventable according to the CNEMM's collegial assessment (see chapter 3). The preventable factors reported are related to inadequate content of care in 94% of cases and/or organisation of care in 44% of cases. In this triennium, maternal death due to haemorrhage occurred mainly in the context of caesarean delivery (65% of cases, i.e. 13/20), and mostly in the context of emergency care (12/13). The main causes of obstetric haemorrhage were uterine rupture (6/20) in unscarred uterus or in association with placenta accreta, and surgical injury during the caesarean delivery (5/20). Every maternity hospital, whatever its resources and/or technical facilities, must be able to plan any obstetric haemorrhage situation that threatens the mother's vital prognosis. Intraperitoneal occult haemorrhage following caesarean section and uterine rupture require immediate surgery with the help of skilled surgeon resources with early and appropriate administration of blood products.
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Affiliation(s)
- Eric Verspyck
- Service de gynécologie-obstétrique, CHU Charles-Nicolle, 1, rue de Germont, 76031 Rouen cedex, France.
| | - Estelle Morau
- Service d'anesthésie-réanimation, CHU de Nîmes, Nîmes, France
| | - Coralie Chiesa-Dubruille
- Département de Maïeutique, Paris Saclay, UFR Simone Veil-Santé, université de Versailles Saint-Quentin-en-Yvelines, Montigny-le-Bretonneux, France; Service de gynécologie-obstétrique, centre hospitalier de Rambouillet, Rambouillet, France
| | - Martine Bonnin
- Pôle femme et enfant, hôpital Estaing, CHU de Clermont-Ferrand, Clermont-Ferrand, France
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12
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Kowalczyk JJ, Cecconi M, Butwick AJ. Evaluating tranexamic acid for the prevention and treatment of obstetric hemorrhage. Curr Opin Obstet Gynecol 2024; 36:88-96. [PMID: 38170626 DOI: 10.1097/gco.0000000000000935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
PURPOSE OF REVIEW Tranexamic acid (TXA) has emerged as a promising pharmacological adjunct to treat and prevent postpartum hemorrhage (PPH). We provide an overview of TXA, including its pharmacology, key findings of randomized trials and observational studies, and critical patient safety information. RECENT FINDINGS Pharmacokinetic data indicate that TXA infusions result in peak plasma concentration within 3 min (range: 1-6.6 min). Ex-vivo pharmacodynamic data suggest that low-dose TXA (5 mg/kg) inhibits maximum lysis for at least 1 h. In predominantly developing countries, TXA has demonstrated a 19% reduction in the risk of bleeding-related death among patients with PPH. Based on high-quality randomized trials, TXA prophylaxis does not effectively reduce the risk of PPH during vaginal delivery and is likely ineffective in reducing the PPH risk during cesarean delivery. TXA exposure does not increase the risk of maternal thrombotic events. Maternal deaths have occurred from accidental intrathecal TXA injection from look-alike medication errors. SUMMARY TXA has shown promise as an important adjunct for PPH treatment, especially in low-resource settings. However, TXA is not recommended as PPH prophylaxis during vaginal or cesarean delivery. Patient safety initiatives should be prioritized to prevent maternal death from accidental intrathecal TXA injection.
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Affiliation(s)
- John J Kowalczyk
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maurizio Cecconi
- Biomedical Sciences Department, Humanitas University
- Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Alexander J Butwick
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
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13
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Hersh AR, Carroli G, Hofmeyr GJ, Garg B, Gülmezoglu M, Lumbiganon P, De Mucio B, Saleem S, Festin MPR, Mittal S, Rubio-Romero JA, Chipato T, Valencia C, Tolosa JE. Third stage of labor: evidence-based practice for prevention of adverse maternal and neonatal outcomes. Am J Obstet Gynecol 2024; 230:S1046-S1060.e1. [PMID: 38462248 DOI: 10.1016/j.ajog.2022.11.1298] [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: 06/06/2022] [Revised: 11/22/2022] [Accepted: 11/23/2022] [Indexed: 03/12/2024]
Abstract
The third stage of labor is defined as the time period between delivery of the fetus through delivery of the placenta. During a normal third stage, uterine contractions lead to separation and expulsion of the placenta from the uterus. Postpartum hemorrhage is a relatively common complication of the third stage of labor. Strategies have been studied to mitigate the risk of postpartum hemorrhage, leading to the widespread implementation of active management of the third stage of labor. Initially, active management of the third stage of labor consisted of a bundle of interventions including administration of a uterotonic agent, early cord clamping, controlled cord traction, and external uterine massage. However, the effectiveness of these interventions as a bundle has been questioned, leading to abandonment of some components in recent years. Despite this, upon review of selected international guidelines, we found that the term "active management of the third stage of labor" was still used, but recommendations for and against individual interventions were variable and not necessarily supported by current evidence. In this review, we: (1) examine the physiology of the third stage of labor, (2) present evidence related to interventions that prevent postpartum hemorrhage and promote maternal and neonatal health, (3) review current global guidelines and recommendations for practice, and (4) propose future areas of investigation. The interventions in this review include pharmacologic agents to prevent postpartum hemorrhage, cord clamping, cord milking, cord traction, cord drainage, early skin-to-skin contact, and nipple stimulation. Treatment of complications of the third stage of labor is outside of the scope of this review. We conclude that current evidence supports the use of effective pharmacologic postpartum hemorrhage prophylaxis, delayed cord clamping, early skin-to-skin contact, and controlled cord traction at delivery when feasible. The most effective uterotonic regimens for preventing postpartum hemorrhage after vaginal delivery include oxytocin plus ergometrine; oxytocin plus misoprostol; or carbetocin. After cesarean delivery, carbetocin or oxytocin as a bolus are the most effective regimens. There is inconsistent evidence regarding the use of tranexamic acid in addition to a uterotonic compared with a uterotonic alone for postpartum hemorrhage prevention after all deliveries. Because of differences in patient comorbidities, costs, and availability of resources and staff, decisions to use specific prevention strategies are dependent on patient- and system-level factors. We recommend that the term "active management of the third stage of labor" as a combined intervention no longer be used. Instead, we recommend that "third stage care" be adopted, which promotes the implementation of evidence-based interventions that incorporate practices that are safe and beneficial for both the woman and neonate.
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Affiliation(s)
- Alyssa R Hersh
- Oregon Health & Science University, Portland, OR; FUNDARED-MATERNA, Bogotá, Colombia.
| | | | - G Justus Hofmeyr
- University of Botswana, Gaborone, Botswana; University of the Witwatersrand, Johannesburg, Johannesburg, South Africa; Walter Sisulu University, Mthatha, South Africa
| | - Bharti Garg
- Oregon Health & Science University, Portland, OR
| | | | - Pisake Lumbiganon
- Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Bremen De Mucio
- Latin American Center for Perinatology, Women and Reproductive Health, Montevideo, Uruguay
| | - Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Mario Philip R Festin
- Department of Obstetrics and Gynecology, College of Medicine, University of the Philippines, Manila, Philippines
| | | | | | - Tsungai Chipato
- Faculty of Health Sciences, Department of Obstetrics and Gynaecology, University of Zimbabwe, Harare, Zimbabwe
| | - Catalina Valencia
- FUNDARED-MATERNA, Bogotá, Colombia; Medicina Fetal SAS, Medellin, Colombia
| | - Jorge E Tolosa
- Oregon Health & Science University, Portland, OR; FUNDARED-MATERNA, Bogotá, Colombia; St. Luke's University Health Network, Bethlehem, PA
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14
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Neef V, Flinspach AN, Eichler K, Woebbecke TR, Noone S, Kloka JA, Jennewein L, Louwen F, Zacharowski K, Raimann FJ. Management and Outcome of Women with Placenta Accreta Spectrum and Treatment with Uterine Artery Embolization. J Clin Med 2024; 13:1062. [PMID: 38398377 PMCID: PMC10888708 DOI: 10.3390/jcm13041062] [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: 12/31/2023] [Revised: 02/02/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Placenta accreta spectrum (PAS) disorders are a continuum of placental pathologies with increased risk for hemorrhage, blood transfusion and maternal morbidity. Uterine artery embolization (UAE) is a safe approach to the standardization of complex PAS cases. The aim of this study is to analyze anemia and transfusion rate, outcome and anesthesiological management of women who underwent caesarean delivery with subsequent UAE for the management of PAS. MATERIAL AND METHODS This retrospective observational study included all pregnant women admitted to the University Hospital Frankfurt between January 2012 and September 2023, with a diagnosis of PAS who underwent a two-step surgical approach for delivery and placenta removal. Primary procedure included cesarean delivery with subsequent UAE, secondary procedure included placenta removal after a minim of five weeks via curettage or HE. Maternal characteristics, anesthesiological management, complications, anemia rate, blood loss and administration of blood products were analyzed. RESULTS In total, 17 women with PAS were included in this study. Of these, 5.9% had placenta increta and 94.1% had placenta percreta. Median blood loss was 300 (200-600) mL during primary procedure and 3600 (450-5500) mL during secondary procedure. In total, 11.8% and 62.5% of women received red blood cell transfusion during the primary and secondary procedures, respectively. After primary procedure, postpartum anemia rate was 76.5%. The HE rate was 64.7%. Regional anesthesia was used in 88.2% during primary procedure. CONCLUSION The embolization of the uterine artery for women diagnosed with PAS is safe. Anemia management and the implementation of blood conservation strategies are crucial in women undergoing UAE for the management of PAS.
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Affiliation(s)
- Vanessa Neef
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (A.N.F.); (T.R.W.); (S.N.); (J.A.K.); (K.Z.); (F.J.R.)
| | - Armin N. Flinspach
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (A.N.F.); (T.R.W.); (S.N.); (J.A.K.); (K.Z.); (F.J.R.)
| | - Katrin Eichler
- Department of Interventional Radiology, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany;
| | - Tirza R. Woebbecke
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (A.N.F.); (T.R.W.); (S.N.); (J.A.K.); (K.Z.); (F.J.R.)
| | - Stephanie Noone
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (A.N.F.); (T.R.W.); (S.N.); (J.A.K.); (K.Z.); (F.J.R.)
| | - Jan A. Kloka
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (A.N.F.); (T.R.W.); (S.N.); (J.A.K.); (K.Z.); (F.J.R.)
| | - Lukas Jennewein
- Department of Obstetrics and Perinatal Medicine, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (L.J.); (F.L.)
| | - Frank Louwen
- Department of Obstetrics and Perinatal Medicine, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (L.J.); (F.L.)
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (A.N.F.); (T.R.W.); (S.N.); (J.A.K.); (K.Z.); (F.J.R.)
| | - Florian J. Raimann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (A.N.F.); (T.R.W.); (S.N.); (J.A.K.); (K.Z.); (F.J.R.)
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15
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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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16
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Vuong ADB, Pham TH, Bui VH, Nguyen XT, Trinh NB, Nguyen YON, Le DKT, Nguyen PN. Successfully conservative management of the uterus in acute pulmonary embolism during cesarean section for placenta previa: a case report from Tu Du Hospital, Vietnam and literature review. Int J Emerg Med 2024; 17:14. [PMID: 38287235 PMCID: PMC10823749 DOI: 10.1186/s12245-024-00587-4] [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: 06/11/2023] [Accepted: 01/12/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Cardiopulmonary collapse is a catastrophic event in cesarean section, which leads to adverse outcomes for both the mother and the fetus. Pulmonary embolism is one of the rare etiologies of this entity. We herein reported the successful management of acute embolism pulmonary associated with cesarean delivery on a healthy pregnant woman at our tertiary referral hospital. CASE PRESENTATION A full-term pregnant woman hospitalized for planned cesarean delivery due to placenta previa without cardiorespiratory diseases. She was scheduled uneventfully for a planned cesarean section. After placental delivery, the patient spontaneously fell into cardiopulmonary collapse and her vital signs deteriorated rapidly. The obstetricians promptly completed the cesarean section and performed all procedures to prevent the PPH and preserve the uterus. At the same time, the anesthesiologists continued to carry out advanced heart-lung resuscitation in order to control her vital signs. After surgery, the multidisciplinary team assessed the patient and found a thrombus in her pulmonary circulation. Therefore, the patient was managed with therapeutic anticoagulation. The patient recovered in good clinical condition and was discharged after 2 weeks without any complications. CONCLUSIONS The diagnosis of acute pulmonary embolism is extremely difficult due to uncommon occurrence, sudden onset, and non-specific presentation. Awareness of this life-threatening pathology during cesarean delivery should be raised. Interdisciplinary assessment must be essentially established in this life-threatening condition. After the whole conventional management, uterine conservation may be acceptable where applicable. Further data is required to encourage this finding.
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Affiliation(s)
- Anh Dinh Bao Vuong
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam
| | - Thanh Hai Pham
- Tu Du Clinical Research Unit (TD-CRU), Tu Du Hospital, Ho Chi Minh City, Vietnam
| | - Van Hoang Bui
- Integrated Planning Room, Tu Du Hospital, Ho Chi Minh City, Vietnam
| | - Xuan Trang Nguyen
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam
| | - Ngoc Bich Trinh
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam
| | - Yen Oanh Ngoc Nguyen
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam
| | - Dang Khoa Tran Le
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam
| | - Phuc Nhon Nguyen
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam.
- Tu Du Clinical Research Unit (TD-CRU), Tu Du Hospital, Ho Chi Minh City, Vietnam.
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17
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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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18
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Jackson TL, Tuuli MG. Intrauterine Postpartum Hemorrhage-Control Devices. Obstet Gynecol 2023; 142:1000-1005. [PMID: 37797338 DOI: 10.1097/aog.0000000000005403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/29/2023] [Indexed: 10/07/2023]
Abstract
Postpartum hemorrhage , defined as a cumulative blood loss of 1,000 mL or more or blood loss associated with signs or symptoms of hypovolemia regardless of the route of delivery, is the leading cause of preventable maternal death worldwide. The United States has one of the highest maternal mortality rates among developed countries, with about 14% of all maternal deaths associated with postpartum hemorrhage. Although postpartum hemorrhage has multiple causes, the most common is uterine atony-when the uterus fails to adequately contract after childbirth-accounting for 80% of all postpartum hemorrhages. When postpartum hemorrhage occurs despite preventive measures, therapeutic measures are used. Intrauterine hemorrhage-control devices are often the second-line therapy when medical management is unsuccessful. Despite its widespread use in current obstetric practice, the mechanism of intrauterine balloon tamponade, such as the Bakri balloon, is counterintuitive to the physiologic uterine contraction that occurs after delivery to control bleeding, and data on its effectiveness are mixed. Vacuum-induced hemorrhage control, such as with the Jada System, cleared by the U.S. Food and Drug Administration in 2020, is a novel modality for control of postpartum bleeding. It mimics postpartum physiology by applying low-level intrauterine negative pressure to facilitate uterine compressive forces, thereby constricting blood vessels to achieve hemostasis. Preliminary data from four studies are promising but are limited by a lack of control groups, selection bias, or modest sample sizes. The results of ongoing and planned randomized controlled trials will clarify the role of the Jada System for reducing morbidity from postpartum hemorrhage.
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Affiliation(s)
- Tracy L Jackson
- Department of Obstetrics and Gynecology, Warren Alpert Medical School at Brown University, and Women and Infants Hospital of Rhode Island, Providence, Rhode Island
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19
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Sentilhes L, Bénard A, Madar H, Froeliger A, Petit S, Deneux-Tharaux C. Tranexamic acid for reduction of blood loss after Caesarean delivery: a cost-effectiveness analysis of the TRAAP2 trial. Br J Anaesth 2023; 131:893-900. [PMID: 37690946 DOI: 10.1016/j.bja.2023.07.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/12/2023] [Accepted: 07/26/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND Prophylactic administration of tranexamic acid is associated with a reduction of blood loss after Caesarean delivery, but cost-effectiveness for this indication has not been assessed. METHODS We used data from the TRAAP2 trial, a multicentre, double-blinded, RCT aimed at estimating the efficacy of tranexamic acid for preventing postpartum haemorrhage among women undergoing Caesarean delivery. Women recruited at 27 French maternity hospitals from 2018 to 2020 were enrolled before the procedure if they had a Caesarean delivery before or during labour at 34 or more weeks of gestation. The main outcomes were the cost of hospital stay for delivery and the incremental cost per delivery without complication within 90 days after delivery with tranexamic acid compared with placebo. Differences in costs and the incremental net monetary benefit (INMB) were estimated using linear regression models, and the cost-effectiveness probability of tranexamic acid compared with placebo was estimated through the parametric distribution of the INMB. RESULTS The proportion of women without complications at day 90 was 70.7% in the tranexamic acid group and 66.0% in the placebo group. Mean total costs until occurrence of a complication of interest were €3321 in the tranexamic acid group and €3260 in the placebo group, resulting in a difference between the two groups of 7.2% and €55 after multiple imputation. The adjusted incremental cost-effectiveness ratio was €762 per additional Caesarean delivery without a complication at 90 days after delivery. At a cost-effectiveness threshold of €10,000, the cost-effectiveness probability of tranexamic acid compared with placebo was 99.9%, varying from 5.8% to 100.0% for thresholds from €0 to €10,000 per additional delivery without a complication at day 90. CONCLUSION Tranexamic acid for the prevention of blood loss is cost-effective in reducing complications after Caesarean delivery at day 90 postpartum. However, the effect size (in cost and effectiveness) is very low. CLINICAL TRIAL REGISTRATION NCT03431805.
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Affiliation(s)
- Loïc Sentilhes
- Department of Obstetrics and Gynaecology, Bordeaux University Hospital, Bordeaux, France.
| | - Antoine Bénard
- CHU Bordeaux, Clinical Epidemiology Unit (USMR), INSERM, Bordeaux Population Health, Bordeaux, France
| | - Hugo Madar
- Department of Obstetrics and Gynaecology, Bordeaux University Hospital, Bordeaux, France
| | - Alizée Froeliger
- Department of Obstetrics and Gynaecology, Bordeaux University Hospital, Bordeaux, France
| | - Solène Petit
- INSERM, Bordeaux Population Health, UMR 1219, Bordeaux, France
| | - Catherine Deneux-Tharaux
- Université de Paris, CRESS, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, DHU Risks in Pregnancy, Paris, France
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20
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Peitsidis P, Iavazzo C, Gkegkes ID, Laganà AS, Makridima S, Tsikouras P. Tranexamic Acid (TXA) for the Hemostatic Treatment of Post-Partum Hemorrhage (PPH): What Key Points Have We Learnt After All These Years? J Clin Med 2023; 12:6385. [PMID: 37835029 PMCID: PMC10573555 DOI: 10.3390/jcm12196385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 09/26/2023] [Indexed: 10/15/2023] Open
Abstract
Post-partum bleeding or post-partum hemorrhage (PPH) is often defined as the loss of more than 500 mL of blood after vaginal delivery or 1000 mL of blood after cesarean section following the delivery of a child [...].
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Affiliation(s)
- Panagiotis Peitsidis
- Department of Obstetrics and Gynecology, Helena Venizelou Hospital, 11521 Athens, Greece
| | - Christos Iavazzo
- Gynaecological Oncology Department, Metaxa Cancer Hospital, 18537 Piraeus, Greece;
| | - Ioannis D. Gkegkes
- Athens Colorectal Laboratory, 11528 Athens, Greece
- Department of Colorectal Surgery, Royal Devon University Healthcare NHS Foundation Trust, Exeter EX2 5DW, UK
| | - Antonio Simone Laganà
- Unit of Obstetrics and Gynecology, “Paolo Giaccone” Hospital, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy
| | - Sophia Makridima
- Department of Obstetrics and Gynecology, Helena Venizelou Hospital, 11521 Athens, Greece
| | - Panagiotis Tsikouras
- Department of Obstetrics and Gynecology, The Democritus University of Thrace, 68100 Alexandroupolis, Greece
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21
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Massoth C, Helmer P, Pecks U, Schlembach D, Meybohm P, Kranke P. [Postpartum Hemorrhage]. Anasthesiol Intensivmed Notfallmed Schmerzther 2023; 58:583-597. [PMID: 37832561 DOI: 10.1055/a-2043-4451] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
Postpartum hemorrhage (PPH) affects about 4% of all deliveries in high-income countries and continues to rise, a trend attributable to the increase in caesarean section rates and maternal morbidity. Preventive measures such as the precautionary administration of uterotonics effectively reduce the risk of severe bleeding irrespective of birth mode. As a time-critical condition and a significant contributor to adverse maternal outcomes, PPH needs to be diagnosed early by measuring, not estimating, blood losses. Institutional treatment algorithms should be available to guide stage-based interdisciplinary management without delay. The main therapy goals are to identify the etiology and stop the bleeding by using uterotonics and mechanical and surgical interventions, to restore hemodynamic stability by volume and transfusion therapy and to optimize hemostasis by laboratory- and viscoelastic assay-guided factor replacement. This review highlights current recommendations for prevention, diagnosis and treatment of PPH.
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22
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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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23
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Hofmeyr GJ. Novel concepts and improvisation for treating postpartum haemorrhage: a narrative review of emerging techniques. Reprod Health 2023; 20:116. [PMID: 37568196 PMCID: PMC10422815 DOI: 10.1186/s12978-023-01657-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Most treatments for postpartum haemorrhage (PPH) lack evidence of effectiveness. New innovations are ubiquitous but have not been synthesized for ready access. NARRATIVE REVIEW Pubmed 2020 to 2021 was searched on 'postpartum haemorrhage treatment', and novel reports among 755 citations were catalogued. New health care strategies included early diagnosis with a bundled first response and home-based treatment of PPH. A calibrated postpartum blood monitoring tray has been described. Oxytocin is more effective than misoprostol; addition of misoprostol to oxytocin does not improve treatment. Heat stable carbetocin has not been assessed for treatment. A thermostable microneedle oxytocin patch has been developed. Intravenous tranexamic acid reduces mortality but deaths have been reported from inadvertent intrathecal injection. New transvaginal uterine artery clamps have been described. Novel approaches to uterine balloon tamponade include improvised and purpose-designed free-flow (as opposed to fixed volume) devices and vaginal balloon tamponade. Uterine suction tamponade methods include purpose-designed and improvised devices. Restrictive fluid resuscitation, massive transfusion protocols, fibrinogen use, early cryopreciptate transfusion and point-of-care viscoelastic haemostatic assay-guided blood product transfusion have been reported. Pelvic artery embolization and endovascular balloon occlusion of the aorta and pelvic arteries are used where available. External aortic compression and direct compression of the aorta during laparotomy or aortic clamping (such as with the Paily clamp) are alternatives. Transvaginal haemostatic ligation and compression sutures, placental site sutures and a variety of novel compression sutures have been reported. These include Esike's technique, three vertical compression sutures, vertical plus horizontal compression sutures, parallel loop binding compression sutures, uterine isthmus vertical compression sutures, isthmic circumferential suture, circumferential compression sutures with intrauterine balloon, King's combined uterine suture and removable retropubic uterine compression suture. Innovative measures for placenta accreta spectrum include a lower uterine folding suture, a modified cervical inversion technique, bilateral uterine artery ligation with myometrial excision of the adherent placenta and cervico-isthmic sutures or a T-shaped lower segment repair. Technological advances include cell salvage, high frequency focussed ultrasound for placenta increta and extra-corporeal membrane oxygenation. CONCLUSIONS Knowledge of innovative methods can equip clinicians with last-resort options when faced with haemorrhage unresponsive to conventional methods.
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Affiliation(s)
- G J Hofmeyr
- Department of Obstetrics and Gynaecology, University of Botswana, Notwane Rd, Gaborone, Botswana.
- Universities of the Witwatersrand and Walter Sisulu, East London, South Africa.
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24
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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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Van Noorden R. Medicine is plagued by untrustworthy clinical trials. How many studies are faked or flawed? Nature 2023; 619:454-458. [PMID: 37464079 DOI: 10.1038/d41586-023-02299-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
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