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Brenner A, Shakur-Still H, Chaudhri R, Muganyizi P, Olayemi O, Arribas M, Kayani A, Javid K, Bello A, Roberts I. Tranexamic acid by the intramuscular or intravenous route for the prevention of postpartum haemorrhage in women at increased risk: a randomised placebo-controlled trial (I'M WOMAN). Trials 2023; 24:782. [PMID: 38044460 PMCID: PMC10694937 DOI: 10.1186/s13063-023-07687-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/28/2023] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND Postpartum haemorrhage (PPH) causes about 70,000 maternal deaths every year. Tranexamic acid (TXA) is a life-saving treatment for women with PPH. Intravenous (IV) TXA reduces deaths due to PPH by one-third when given within 3 h of childbirth. Because TXA is more effective when given early and PPH usually occurs soon after childbirth, giving TXA just before childbirth might prevent PPH. Although several randomised trials have examined TXA for PPH prevention, the results are inconclusive. Because PPH only affects a small proportion of births, we need good evidence on the balance of benefits and harms before using TXA to prevent PPH. TXA is usually given by slow IV injection. However, recent research shows that TXA is well tolerated and rapidly absorbed after intramuscular (IM) injection, achieving therapeutic blood levels within minutes of injection. METHODS The I'M WOMAN trial is an international, multicentre, three-arm, randomised, double-blind, placebo-controlled trial to assess the effects of IM and IV TXA for the prevention of PPH in women with one or more risk factors for PPH giving birth vaginally or by caesarean section. DISCUSSION The trial will provide evidence of the benefits and harms of TXA for PPH prevention and the effects of the IM and IV routes of administration. The IM route should be as effective as the IV route for preventing bleeding. There may be fewer side effects with IM TXA because peak blood concentrations are lower than with the IV route. IM TXA also has practical advantages as it is quicker and simpler to administer. By avoiding the need for IV line insertion and a slow IV injection, IM administration would free up overstretched midwives and doctors to focus on looking after the mother and baby and expand access to timely TXA treatment. TRIAL REGISTRATION ClinicalTrials.gov NCT05562609. Registered on 3 October 2022. ISRCTN Registry ISRCTN12590098. Registered on 20 January 2023. Pan African Clinical Trial Registry PACTR202305473136570. Registered on 18 May 2023.
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Affiliation(s)
- Amy Brenner
- London School of Hygiene & Tropical Medicine, London, United Kingdom.
| | | | | | | | | | - Monica Arribas
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Aasia Kayani
- Shifa Tameer-E-Millat University, Islamabad, Pakistan
| | - Kiran Javid
- Shifa Tameer-E-Millat University, Islamabad, Pakistan
| | | | - Ian Roberts
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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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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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 60] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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Prior CH, Burlinson CEG, Chau A. Emergencies in obstetric anaesthesia: a narrative review. Anaesthesia 2022; 77:1416-1429. [PMID: 36089883 DOI: 10.1111/anae.15839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2022] [Indexed: 11/28/2022]
Abstract
We conducted a narrative review in six areas of obstetric emergencies: category-1 caesarean section; difficult and failed airway; massive obstetric haemorrhage; hypertensive crisis; emergencies related to neuraxial anaesthesia; and maternal cardiac arrest. These areas represent significant research published within the last five years, with emphasis on large multicentre randomised trials, national or international practice guidelines and recommendations from major professional societies. Key topics discussed: prevention and management of failed neuraxial technique; role of high-flow nasal oxygenation and choice of neuromuscular drug in obstetric patients; prevention of accidental awareness during general anaesthesia; management of the difficult and failed obstetric airway; current perspectives on the use of tranexamic acid, fibrinogen concentrate and cell salvage; guidance on neuraxial placement in a thrombocytopenic obstetric patient; management of neuraxial drug errors, local anaesthetic systemic toxicity and unusually prolonged neuraxial block regression; and extracorporeal membrane oxygenation use in maternal cardiac arrest.
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Affiliation(s)
- C H Prior
- Department of Anaesthesia, West Middlesex University Hospital, London, UK
| | - C E G Burlinson
- Department of Anesthesia, BC Women's Hospital, Vancouver, BC, Canada.,Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - A Chau
- Department of Anesthesia, BC Women's Hospital, Vancouver, BC, Canada.,Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada.,Department of Anesthesia, St. Paul's Hospital, Vancouver, BC, Canada
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Improving Development of Drug Treatments for Pregnant Women and the Fetus. Ther Innov Regul Sci 2022; 56:976-990. [PMID: 35881237 PMCID: PMC9315086 DOI: 10.1007/s43441-022-00433-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/30/2022] [Indexed: 12/12/2022]
Abstract
The exclusion of pregnant populations, women of reproductive age, and the fetus from clinical trials of therapeutics is a major global public health issue. It is also a problem of inequity in medicines development, as pregnancy is a protected characteristic. The current regulatory requirements for drugs in pregnancy are being analyzed by a number of agencies worldwide. There has been considerable investment in developing expertise in pregnancy clinical trials (for the pregnant person and the fetus) such as the Obstetric-Fetal Pharmacology Research Centers funded by the National Institute of Child Health and Human Development. Progress has also been made in how to define and grade clinical trial safety in pregnant women, the fetus, and neonate. Innovative methods to model human pregnancy physiology and pharmacology using computer simulations are also gaining interest. Novel ways to assess fetal well-being and placental function using magnetic resonance imaging, computerized cardiotocography, serum circulating fetoplacental proteins, and mRNA may permit better assessment of the safety and efficacy of interventions in the mother and fetus. The core outcomes in women’s and newborn health initiative is facilitating the consistent reporting of data from pregnancy trials. Electronic medical records integrated with pharmacy services should improve the strength of pharmacoepidemiologic and pharmacovigilance studies. Incentives such as investigational plans and orphan disease designation have been taken up for obstetric, fetal, and neonatal diseases. This review describes the progress that is being made to better understand the extent of the problem and to develop applicable solutions.
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McDougall ARA, Goldstein M, Tuttle A, Ammerdorffer A, Rushwan S, Hastie R, Gülmezoglu AM, Vogel JP. Innovations in the prevention and treatment of postpartum hemorrhage: Analysis of a novel medicines development pipeline database. Int J Gynaecol Obstet 2022; 158 Suppl 1:31-39. [PMID: 35762804 PMCID: PMC9328148 DOI: 10.1002/ijgo.14200] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background A significant barrier to improving prevention and treatment of postpartum hemorrhage (PPH) is a lack of innovative medicines that meet the needs of women and providers, particularly those in low‐and middle‐income countries (LMICs). The Accelerating Innovation for Mothers (AIM) project established a new database of candidate medicines under development for five pregnancy‐related conditions between 2000 and 2021. Objective To systematically identify and rank candidates for prevention and treatment of PPH. Search Strategy Adis Insight, Pharmaprojects, WHO ICTRP, PubMed, and grant databases were searched to develop the AIM database. Selection Criteria AIM database was searched for candidates being evaluated for PPH prevention and treatment, regardless of phase. Data Collection and Analysis Candidates were ranked as high, medium, or low potential based on prespecified criteria. Analysis was primarily descriptive, describing candidates and development potential. Main Results Of the 444 unique candidates, only 39 pertained to PPH. One was high potential (heat‐stable/inhaled oxytocin) and three were medium potential (melatonin, vasopressin and dofetilide via nanoparticle delivery). Conclusion The pipeline for new PPH medicines is concerningly limited, lacking diversity, and showing little evidence of novel technologies. Without significant investment in early‐phase research, it is unlikely that new products will emerge. A new database of maternal medicine development shows few new PPH candidates are in the pipeline. Significant investment is needed, particularly in early‐phase research.
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Affiliation(s)
- Annie R A McDougall
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia
| | | | | | | | | | - Roxanne Hastie
- Department of Obstetrics and Gynecology, University of Melbourne, Heidelberg, Australia
| | | | - Joshua P Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Shakur‐Still H, Grassin‐Delyle S, Muhunthan K, Ahmadzia HK, Faraoni D, Arribas M, Roberts I. Alternative routes to intravenous tranexamic acid for postpartum hemorrhage: A systematic search and narrative review. Int J Gynaecol Obstet 2022; 158 Suppl 1:40-45. [PMID: 35762806 PMCID: PMC9327714 DOI: 10.1002/ijgo.14201] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
OBJECTIVE To review available data on tranexamic acid (TXA) plasma concentration needed to inhibit fibrinolysis and the time to achieve this concentration when giving TXA by different routes in humans. To identify ongoing trials assessing alternatives to intravenous TXA administration. METHODS We updated two previous systematic reviews by searching MEDLINE, EMBASE, OviSP, and ISI Web of Science from database inception to July 2021. We also searched the WHO International Clinical Trials Registry Platform for ongoing trials to July 2021. Titles and abstracts were screened for relevant trials. Two reviewers independently reviewed and agreed the trials to be included. RESULTS Plasma TXA concentrations over 10 mg/L provide near maximal inhibition of fibrinolysis, with concentrations over 5 mg/L providing partial inhibition. Oral TXA tablets take about 1 h to reach a plasma concentration of 5 mg/L in postpartum women. Studies in healthy volunteers and shocked trauma patients show that intramuscular TXA achieves a plasma level of over 10 mg/L within 15 min. One trial is ongoing to determine the pharmacokinetics of intramuscular and oral solution TXA in pregnant women. CONCLUSION Intramuscular TXA in healthy volunteers and shocked trauma patients reaches therapeutic concentration rapidly. Oral TXA tablets take too long to reach the minimum therapeutic concentration in postpartum women.
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Affiliation(s)
| | - Stanislas Grassin‐Delyle
- Département des maladies des voies respiratoiresHôpital FochSuresnesFrance
- Infection et inflammation, Département de Biotechnologie de la Santé, UVSQ, INSERMUniversité Paris‐SaclayMontigny le BretonneuxFrance
| | | | - Homa K. Ahmadzia
- Department of Obstetrics and Gynecology, Division of Maternal‐Fetal MedicineGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - David Faraoni
- Department of Anesthesiology, Perioperative and Pain Medicine, Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Texas Children’s HospitalBaylor College of MedicineHoustonTexasUSA
| | - Monica Arribas
- Clinical Trials UnitLondon School of Hygiene and Tropical MedicineLondonUK
| | - Ian Roberts
- Clinical Trials UnitLondon School of Hygiene and Tropical MedicineLondonUK
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Bellos I, Pergialiotis V. Tranexamic acid for the prevention of postpartum hemorrhage in women undergoing cesarean delivery: an updated meta-analysis. Am J Obstet Gynecol 2022; 226:510-523.e22. [PMID: 34582795 DOI: 10.1016/j.ajog.2021.09.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/16/2021] [Accepted: 09/21/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE This study aimed to assess the efficacy and safety of prophylactic tranexamic acid administration vs standard uterotonic agents alone among women undergoing cesarean delivery. DATA SOURCES MEDLINE, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and Google Scholar were systematically searched from inception to June 30, 2021. STUDY ELIGIBILITY CRITERIA Randomized controlled trials comparing intravenous tranexamic acid administration with placebo in women undergoing cesarean delivery and receiving standard prophylactic uterotonic agents were held eligible. STUDY APPRAISAL AND SYNTHESIS METHODS The risk of bias of individual studies was appraised with the Risk of Bias 2 tool. Meta-analysis was conducted by fitting random-effects models using restricted maximum likelihood. Subgroup analysis was performed on the basis of country, protocol availability, double-blinding, risk of bias, sample size, and tranexamic acid dose. A 1-stage meta-analysis was performed as a sensitivity analysis. The credibility of outcomes was appraised with the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS Overall, 36 studies with 10,659 women were included. Tranexamic acid administration was associated with significantly lower total blood loss (mean difference, -189.44 mL; 95% confidence intervals, -218.63 to -160.25), lower hemoglobin drop (mean difference, 8.22%; 95% confidence interval, 5.54-10.90), decreased risk of blood loss of >1000 mL (odds ratio, 0.37; 95% confidence interval, 0.22-0.60), transfusion requirement (odds ratio, 0.41; 95% confidence interval, 0.26-0.65), and need of additional uterotonics (odds ratio, 0.36; 95% confidence interval, 0.25-0.52). Subgroup analysis indicated a greater effect of tranexamic acid on total blood loss reduction in low-middle income countries. The outcomes remained stable by separately evaluating women at low bleeding risk. The 1-stage meta-analysis demonstrated similar outcomes with the primary analysis. The quality of evidence was judged to be moderate regarding total blood loss and hemoglobin percentage change and low for the other outcomes. CONCLUSION This meta-analysis suggested that prophylactic tranexamic acid administration is effective among women undergoing cesarean delivery in lowering postpartum blood loss and limiting hemoglobin drop. Further research is needed to test its efficacy in high-risk populations and verify its safety profile.
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Affiliation(s)
- Ioannis Bellos
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - Vasilios Pergialiotis
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Bouthors AS, Gilliot S, Faraoni D, Sentilhes L. Antifibrinolytic agents for the prevention of postpartum hemorrhage. THROMBOSIS UPDATE 2021. [DOI: 10.1016/j.tru.2021.100089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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