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Ragusa A, Ficarola F, Ferrari A, Spirito N, Ardovino M, Giraldi D, Stuzziero E, Rinaldo D, Procaccianti R, Larciprete G, De Luca C, D'Avino S, Principi G, Angioli R, Svelato A. Tranexamic acid versus oxytocin prophylaxis in reducing post-partum blood loss, in low-risk pregnant women: TRANOXY STUDY, a phase III randomized clinical trial. EClinicalMedicine 2024; 73:102665. [PMID: 38873634 PMCID: PMC11169955 DOI: 10.1016/j.eclinm.2024.102665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 05/08/2024] [Accepted: 05/10/2024] [Indexed: 06/15/2024] Open
Abstract
Background To assess the equivalence of tranexamic acid (TRAN) versus synthetic oxytocin (OXY) in reducing post-partum blood loss, in full-term patients (37-42 weeks), at low risk of post-partum hemorrhage, with vaginal childbirth. Methods Phase III, randomized (1:1), open-label, longitudinal, multi-center, prospective clinical trial (Prot. n 63209, ClinicalTrials.gov Identifier: NCT02775773). From January 7, 2020, to June 30, 2023, a total of 256 women were enrolled at two general urban community hospitals in Italy, serving a multi-ethnic patient population with National Health Insurance. The primary outcome was to explore a potential equivalence between the two treatments (OXY and TRAN) in preventing total blood loss. Therefore, we randomized 231 women into two groups: Group A (OXY), 127 women who were administered 10UI intramuscularly within 5 min from childbirth; Group B (TRAN), 104 women to whom 1-g slow intravenous infusion was administered within 5 min from childbirth. Findings At the time of delivery, mean blood loss for OXY group versus TRAN group was 269.12 mL versus 263.88 mL, respectively, with equivalence between the two groups. Similarly, there was equivalence in total blood loss between the OXY and the TRAN group (397.66 mL versus 405.64 mL, respectively. No statistical differences between Hb levels at admission and discharge in the two groups were reported. No difference was found in terms of additional uterotonic and surgical therapies between the two groups of patients. Neither group showed thrombotic complications at check-up performed after 7 days or after a questionnaire regarding adverse effects, subjected after 40 days. Interpretation The study shows the equivalence of tranexamic acid versus synthetic oxytocin in post-partum blood loss prophylaxis in term patients at low risk of PPH with vaginal childbirth. The safety profiles of OXY and TRAN were similar. Funding None.
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Affiliation(s)
- Antonio Ragusa
- Department of Obstetrics and Gynecology, Maggiore Hospital Carlo Alberto Pizzardi Bologna, Italy
| | - Fernando Ficarola
- Unit of Gynecology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Unit of Gynecology, Department of Surgical and Medical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Amerigo Ferrari
- Institute of Management, MeS (Management and Health) Laboratory, Sant’Anna School of Advanced Studies, Pisa, Italy
| | - Nicoletta Spirito
- Department of Obstetrics and Gynecology, Ospedale Apuane, Massa Carrara, Italy
| | - Mario Ardovino
- Department of Obstetrics and Gynecology, Ospedale S.G. Moscati, Avellino, Italy
| | - Domenico Giraldi
- Department of Obstetrics and Gynecology, Ospedale S.G. Moscati, Avellino, Italy
| | - Elisario Stuzziero
- Department of Obstetrics and Gynecology, Ospedale S.G. Moscati, Avellino, Italy
| | - Denise Rinaldo
- Department of Obstetrics and Gynecology, ASST Bergamo Est, Bolognini Hospital, Seriate, Italy
| | - Roberto Procaccianti
- Department of Gynecology and Obstetrics, Fondazione Istituto San Raffaele G Giglio, Cefalù, Italy
| | - Giovanni Larciprete
- Department of Obstetrics and Gynecology, Fatebenefratelli Gemelli Hospital, Isola Tiberina, Roma, Italy
| | - Caterina De Luca
- Department of Obstetrics and Gynecology, Fatebenefratelli Gemelli Hospital, Isola Tiberina, Roma, Italy
| | - Sara D'Avino
- Department of Obstetrics and Gynecology, Fatebenefratelli Gemelli Hospital, Isola Tiberina, Roma, Italy
| | - Giulia Principi
- Department of Obstetrics and Gynecology, University of Messina, Messina, Italy
| | - Roberto Angioli
- Unit of Gynecology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Alessandro Svelato
- Department of Obstetrics and Gynecology, Fatebenefratelli Gemelli Hospital, Isola Tiberina, Roma, Italy
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Pang FS, Liaw EYF, De S. Comprehensive management of Jehovah's Witness in pregnancy. Postgrad Med J 2023; 99:1068-1075. [PMID: 37334974 DOI: 10.1093/postmj/qgad047] [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: 02/08/2023] [Revised: 03/16/2023] [Accepted: 05/13/2023] [Indexed: 06/21/2023]
Abstract
Jehovah's Witness (JW) is a denomination of Christianity which has many-fold higher morbidity and mortality compared to the general population as they refuse blood transfusion. Information is scanty regarding guidelines on the optimal approach to pregnant ladies of JW faith. In this review we have attempted to analyse the ways and techniques available which can be used to reduce the morbidity and mortality of these women. In antenatal care, haematological status can be optimised to reduce modifiable risk factors, namely anaemia by parenteral iron therapy from the second trimester onwards especially in patients who do not respond to oral iron therapy. In severe cases, erythropoietin serves as an effective alternative to blood transfusion. During the intrapartum period, using antifibrinolytics, cell salvage, bloodless surgical techniques, and uterine cooling for patients undergoing caesarean delivery have been proven effective. To conclude, complications of pregnant JW patients may be reduced if they comply with the preventives and targeted monitoring during the various phases of pregnancy. Further studies are warranted as this population exists as a minor group but is growing worldwide. KEY MESSAGES CURRENT RESEARCH QUESTIONS
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Affiliation(s)
- Fei San Pang
- Department of Obstetrics and Gynaecology, Manipal University College, 75150 Melaka, Malaysia
| | - Elvin Yee Fan Liaw
- Department of Obstetrics and Gynaecology, Manipal University College, 75150 Melaka, Malaysia
| | - Somsubhra De
- Department of Obstetrics and Gynaecology, Manipal University College, 75150 Melaka, Malaysia
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Entezari B, Wolford LM, Gunn DC, Murillo S, Ramamoorthy S. Tranexamic Acid Use Intra-Operatively Decreases the Need for Blood Transfusions and Post-Operative Edema in Temporomandibular Joint Surgeries. Cureus 2022; 14:e31569. [DOI: 10.7759/cureus.31569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2022] [Indexed: 11/17/2022] Open
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Postpartum Hemorrhage: Emergency Management for Uncontrolled Vaginal Bleeding. Adv Emerg Nurs J 2022; 44:213-219. [PMID: 35900241 DOI: 10.1097/tme.0000000000000421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Postpartum hemorrhage (PPH) represents total cumulative blood loss in excess of 1,000 ml or blood loss accompanied by signs and/or symptoms of hypovolemia within 24 hr following birth (The American College of Obstetricians and Gynecologists [ACOG], 2017). As a large number of PPHs occur in low-risk women (ACOG, 2019), the emergency nurse practitioner must be prepared to identify and manage this uncommon but life-threatening condition. The etiology, pharmacological management strategies, and other interventions are reviewed in an algorithmic approach. This organized approach not only supports maternal survival during PPH but is also applicable to postprocedural bleeding of obstetric and gynecological etiologies.
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Midwives' experiences of reducing maternal morbidity and mortality from postpartum haemorrhage (PPH) in Eastern Nigeria. BMC Pregnancy Childbirth 2022; 22:474. [PMID: 35676645 PMCID: PMC9175340 DOI: 10.1186/s12884-022-04804-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 05/26/2022] [Indexed: 11/10/2022] Open
Abstract
Background Postpartum haemorrhage (PPH) is one of the major complications of childbirth which may result in maternal morbidity and mortality, especially in low and middle-income countries like Nigeria. Midwives play a vital role in preventing and managing PPH in Nigerian rural communities. The aim of this study is to understand the experiences of midwives in rural maternity care settings in order to provide appropriate support and improve practice. Methods An exploratory, qualitative study of a purposive sample of 15 practicing midwives was carried out using semi-structured interviews from November 2018 to February 2019. Data were transcribed verbatim and analyzed using content analysis. Results Four themes were identified: 1. interventions for preventing PPH; 2. approaches to managing PPH; 3. challenges of preventing and managing PPH and 4. ways of supporting midwives to overcome these challenges in rural health care settings. Midwives employed various strategies, such as antenatal education, diagnosis and treatment of anaemia to counteract complications from possible PPH. Understanding PPH as a life-threatening condition enabled the midwives to provide holistic and effective management that sometimes involved a multidisciplinary team approach. Inadequate resources and delay in seeking health care, however, militate against their efforts. The midwives also identified the need for continuing education and training to enhance their standards of care. Conclusion These midwives in Nigerian rural health care settings engage in preventive practices and active management of PPH though not without barriers, such as inadequate resources. There is a need for midwives in rural areas to have cultural competence, be provided with adequate resources and participate in ongoing education in order to be more effective. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04804-x.
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Goldstein K, Jones C, Kay J, Shin J, de Sa D. Tranexamic Acid Administration in Arthroscopic Surgery Is a Safe Adjunct to Decrease Postoperative Pain and Swelling: A Systematic Review and Meta-analysis. Arthroscopy 2022; 38:1366-1377.e9. [PMID: 34655767 DOI: 10.1016/j.arthro.2021.10.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 10/03/2021] [Accepted: 10/03/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To systematically screen the literature in an effort to critically examine the effect of tranexamic acid (TXA) in patients undergoing arthroscopic surgery, specifically pertaining to pain, blood loss, length of surgery, and both major and minor complications. METHODS In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) guidelines, 3 databases (MEDLINE, EMBASE, and Cochrane) were searched April 2020 and screened in duplicate using inclusion and exclusion criteria for studies on the given subject. Study findings were reviewed, and meta-analysis was then performed on sufficiently congruent data using a random-effects model. RESULTS There were 7 eligible randomized controlled trials, with 724 total patients, undergoing anterior cruciate ligament reconstruction (4 studies, 537 patients), meniscectomy (1 study, 45 patients), femoroacetabular impingement (1 study, 70 patients), or rotator cuff repair (1 study, 72 patients). The mean age throughout the included studies was 33.9 years, with a mean of 27.7% female patients. There was a 1% drop out rate at 3 months postoperatively. There were significantly lower visual analog scale scores at 2 weeks postoperatively in the TXA groups (mean difference: -1.65, 95% confidence interval [CI] -3.41 to 0.10, P = .06, I2 = 97%). Furthermore, there was a significant decrease in the number of patients requiring joint aspiration in the TXA groups (risk ratio 0.27, 95% CI 0.12-0.56, I2 = 0%, P = .0006). The drainage output in TXA groups was also significantly decreased (mean difference: -61.14 mL, 95% CI -104.43 to -17.85, I2 = 94%, P = .006). Furthermore, there was a statistically significant decrease in hemarthrosis grade (Coupens & Yates) at 2 weeks postoperatively (Mean difference: -0.76, 95% CI -0.97 to -0.54, I2 = 0%, P < .0001). Finally, there was no significant difference in operating time, across all studies (Mean difference: 0.53, 95% CI -3.43 to 4.50, I2 = 57%, P < .79). The use of TXA showed no increased incidence of deep vein thrombosis, infection, arthrofibrosis, or other major complications or adverse reactions between the TXA and control groups. CONCLUSIONS This systematic review and meta-analysis of randomized controlled trialss found that the use of TXA significantly improves pain scores up to 6 weeks postoperatively, decreases drainage output, decreases the need for joint aspirations, decreases incidence of hemarthrosis, increases visual clarity and technical ease, and has no increased incidence of other complications, at no loss to operative time. These findings indicate that TXA may be a useful adjunct in arthroscopic knee and shoulder surgery. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Kyle Goldstein
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario
| | - Conor Jones
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario
| | - Jeffrey Kay
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario
| | - Jason Shin
- Department of Orthopaedic Surgery. University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Darren de Sa
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario.
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Skalska-Świstek M, Huras H, Jaworowski AP, Świstek R, Kołak M. COVID-19 Infection Complicated by Disseminated Intravascular Coagulation during Pregnancy—Two Cases Report. Diagnostics (Basel) 2022; 12:diagnostics12030655. [PMID: 35328208 PMCID: PMC8947359 DOI: 10.3390/diagnostics12030655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 02/24/2022] [Accepted: 03/01/2022] [Indexed: 11/25/2022] Open
Abstract
Coagulopathies are one of the obstetric complications affecting the period of pregnancy, childbirth, and puerperium. One of the more severe and complex disorders of the haemostatic system is the disseminated intravascular coagulation syndrome (DIC), in which generalised activation of the coagulation system and activation of inflammatory cells occurs. DIC syndrome was observed in patients whose pregnancy was complicated by SARS-CoV-2 infection. Both the course of these cases and literature review indicate that particular notice should be paid to laboratory parameters of the coagulation system, closely monitoring the well-being of the foetus and, in the situation of acute DIC development, it is advised to deliver a baby and initiate intensive therapy.
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Affiliation(s)
- Małgorzata Skalska-Świstek
- Department of Obstetrics and Perinatology, Medical College, Jagiellonian University, 23 Kopernika Str., 31-501 Krakow, Poland; (H.H.); (A.P.J.); (M.K.)
- Correspondence:
| | - Hubert Huras
- Department of Obstetrics and Perinatology, Medical College, Jagiellonian University, 23 Kopernika Str., 31-501 Krakow, Poland; (H.H.); (A.P.J.); (M.K.)
| | - Andrzej Piotr Jaworowski
- Department of Obstetrics and Perinatology, Medical College, Jagiellonian University, 23 Kopernika Str., 31-501 Krakow, Poland; (H.H.); (A.P.J.); (M.K.)
| | - Rafał Świstek
- Department of Anaesthesiology and Intensive Therapy, University Hospital in Krakow, 2 Jakubowskiego Str., 30-688 Krakow, Poland;
| | - Magdalena Kołak
- Department of Obstetrics and Perinatology, Medical College, Jagiellonian University, 23 Kopernika Str., 31-501 Krakow, Poland; (H.H.); (A.P.J.); (M.K.)
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Howard DC, Jones MAE, Skeith A, Lai J, D'Souza R, Caughey AB. Tranexamic Acid for the Treatment of Postpartum Hemorrhage: A Cost-Effectiveness Analysis. Am J Obstet Gynecol MFM 2022; 4:100588. [PMID: 35124299 DOI: 10.1016/j.ajogmf.2022.100588] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/29/2022] [Accepted: 01/31/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Postpartum hemorrhage (PPH) is a leading cause of pregnancy-related morbidity and mortality. Recent data has demonstrated that tranexamic acid (TXA) reduces death due to bleeding when used as a treatment for PPH. The World Health Organization (WHO) now recommends TXA as a first-line treatment for PPH, however data is not yet available on the frequency of use in the United States, where TXA is currently recognized as an adjunct treatment for PPH. OBJECTIVE We aimed to strengthen the current evidence that TXA should be recognized as a first-line treatment for PPH, even in high-resource countries. Furthermore, we aimed to determine whether early administration of TXA (within 3 hours of diagnosis) is a cost-effective strategy for reducing maternal morbidity and mortality from PPH in the United States. STUDY DESIGN A decision analytic model was designed in order to compare the outcomes and costs of TXA use in the treatment of PPH. This model was then used to compare outcomes for early administration with those of routine use. The interventions compared were 1 gram of intravenous TXA or matching placebo. The risks analyzed in the model were death due to hemorrhage and laparotomy to control bleeding. Probabilities, utilities, and costs were derived from literature. Quality-adjusted life years (QALYs) were calculated using a discounted life expectancy rate of 3 percent. Cost-effectiveness was determined based on a willingness-to-pay threshold of $100,000 per QALY. RESULTS Administration of TXA to theoretical cohort of 100,000 women would prevent 11 maternal deaths, 6 postpartum laparotomies after vaginal delivery, and 112 re-operations after cesarean delivery. This would lead to an increase in 329 QALYs and a total cost savings of 15.39 million. Furthermore, if TXA were administered early (within 3 hours of PPH diagnosis) to the same theoretical cohort, 16 maternal deaths due to hemorrhage, 9 laparotomies, and 155 re-operations would be prevented. This amounts to an increase in 438 QALYs and an annual cost savings of $23.15 million. Sensitivity analysis showed that the administration of TXA was the dominant strategy at all probabilities of maternal death due to hemorrhage greater than 0.00002. When the cost of TXA was varied, TXA use remained dominant up to a cost of $267 per administration in the US if given within the first 3 hours. Furthermore, in a Monte-Carlo probabilistic sensitivity analysis, the early administration of TXA remained the dominant strategy (both lowered costs and improved outcomes) in 99.8% of models. CONCLUSION Early administration of TXA is a cost-effective strategy for reducing maternal morbidity and mortality due to postpartum hemorrhage in the US.
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Affiliation(s)
- Dagnie C Howard
- University of Arizona, Tucson, AZ; Oregon Health & Science University, Portland, OR.
| | | | - Ashley Skeith
- University of Michigan, Ann Arbor, MI; Oregon Health & Science University, Portland, OR
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Obermeyer S, Mielke RT, Lederhos HL. The Role of Perinatal Nurses in the Use of Tranexamic Acid During Postpartum Hemorrhage. Nurs Womens Health 2022; 26:63-71. [PMID: 35065079 DOI: 10.1016/j.nwh.2021.12.003] [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: 03/08/2021] [Revised: 07/10/2021] [Accepted: 12/08/2021] [Indexed: 06/14/2023]
Abstract
Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality worldwide. Mitigation of PPH is dependent on identification of risk, readiness, timely identification of hemorrhage, accurate determination of blood loss, and effective treatment. Perinatal nurses must be prepared to participate in all these aspects of care, including the use of tranexamic acid, an antifibrinolytic agent that has more recently been added to the pharmacologic agents used to reduce blood loss associated with hemorrhage. The purpose of this article is to identify the nurse's role in the management of PPH and to introduce the use of tranexamic acid in PPH management as part of the nurse's role in implementing best practices for PPH.
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