Coagulation management and transfusion in massive postpartum hemorrhage

The effect of the use of tranexamic acid in percutaneous nephrolithotomy on blood loss and surgical visual clarity: a prospective, randomized, controlled and double-blind study

Tranexamic acid, once a randomly used antifibrinolytic agent, has been in standard protocols for many specific surgeries. Studies are still needed to standardize the dose and route of tranexamic acid administration, examine its possible contributions in urological surgery, and establish a protocol for its use. To contribute to this goal, we designed a prospective, randomized, double-blind study on 75 patients with 1 control and 2 study groups (n = 25) who underwent percutaneous nephrolithotomy. Group Tranexamic acid received 10 mg/kg intravenous tranexamic acid preoperatively. And Group Irrigation received the same amount in the initial irrigation fluid. Primarily, we observed the total amount of blood transfusion and the changes in hemoglobin and hematocrit values during 2 postoperative days. Distinctively, we intraoperatively monitored hemoglobin continuously as a saturation hemoglobin value to assess the timing of the effect of tranexamic acid. Secondarily, we questioned surgical visual clarity with a standard visual score to reveal its contribution to surgical practicality, operative time, and residual fragment quantity. Our results revealed a significant difference in the reduction of hemoglobin and hematocrit change and blood transfusion in both tranexamic acid groups concerning control, especially on the second day (p = 0.003, p = 0.002, p = 0.001). Likewise, surgical visual scores were significantly better in both tranexamic acid groups (p = 0.018). In conclusion, intravenous or local administration of tranexamic acid at a dose of 10 mg/kg will be sufficient to maintain perioperative stability in hemoglobin values, use fewer blood products and provide a better visual advantage for the surgeon intraoperatively.The trial registration number is NCT05947435, and the date of registration is 07/07/2023, retrospectively registered.

Impact of Melatonin as a Premedication Agent in Caesarean Section on Blood Loss and Postoperative Pain Level

Background

Postpartum hemorrhage (PPH) is a serious postdelivery condition with a high incidence of morbidity and mortality for women who undergo childbirth with or without a caesarean section. Melatonin has been suggested to increase the contractility of myometrium and reduce the pain score postoperatively, therefore it is believed that the use of melatonin before surgery may decrease blood loss, reduce pain score, and decrease the need for postoperative opioids.

Objectives

The main objectives of this study are focused on the investigation of melatonin as a premedication agent to reduce blood loss and decrease pain score postoperatively in patients undergoing cesarean section under spinal anesthesia.

Methods

80 patients were scheduled for spinal anesthesia-based cesarean sections and randomly assigned to two groups, melatonin group (M) 40 patients and placebo group (P) 40 patients to receive either 10 mg of sublingual melatonin or a placebo of 90 minutes preoperatively. Hemoglobin levels were been measured preoperative and 12 hrs. Postoperatively, blood loss volume was calculated by measuring both the weight of used materials before and after the surgery and the volume sucked in the suction bottle after placental delivery. Postoperative visual pain score and analgesic requirements were used to evaluate pain levels.

Results

Analyzed collected data showed a significant decrease in blood loss in the melatonin group in comparison with the placebo group as measured by the hemoglobin level. On the other hand, there is a significant decrease in pain score and analgesia requirement with the melatonin group compared to the placebo group.

Conclusion

Melatonin is a promising premedication drug that has a significant impact on postpartum hemorrhage by reducing blood loss and pain levels of mothers who have undergone C-sections.

Postpartum maternal tachycardia - diagnostic pitfalls!

PURPOSE OF REVIEW

Maternal tachycardia is a common sign with a multitude of causes. We attempt to look at the most common sinister ones in the postpartum period.

RECENT FINDINGS

Current guidelines differ in the definition of maternal tachycardia. It has been associated with adverse outcomes such as increased length of stay as well as higher mortality if there is underlying peripartum cardiomyopathy. Some recent studies look at common investigations and how these apply to peripartum women, such as ECG markers of arrhythmogenesis, reference ranges for PCT and echocardiogram findings during pregnancy prior to diagnosis of peripartum cardiomyopathy.

SUMMARY

Physiological changes make it difficult to interpret maternal tachycardia and thus how best to manage it. We propose the idea of a three-step approach for the assessment of patients, aiming to identify causes including tachyarrhythmias, obstetric haemorrhage, sepsis, venous thromboembolism and peripartum cardiomyopathy.The first step 'BEDSIDE' applies to all patients looking at observations, history and examination. The second step 'BASIC', applies to most patients and covers ECG and basic blood tests. The final step 'EXTRA' assesses the need for further investigations including additional blood tests and imaging. By using this model, clinicians and healthcare professionals should be able to rationalise the need for more invasive investigations whilst maintain good high-quality care.