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Hernandez MM, Buckley A, Mills A, Meislin R, Cromwell C, Bianco A, Strong N, Arinsburg S. Multidisciplinary management of a pregnancy complicated by Glanzmann thrombasthenia: A case report. Transfusion 2023; 63:2384-2391. [PMID: 37952246 DOI: 10.1111/trf.17594] [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: 03/29/2022] [Revised: 09/05/2023] [Accepted: 09/05/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Glanzmann thrombasthenia (GT) is a rare, autosomal recessive disorder of platelet glycoprotein IIb-IIIa receptors. Pregnant patients with GT are at increased risk of maternal and fetal bleeding. There is a paucity of literature on the peripartum management of patients. CASE DESCRIPTION We present the antepartum through the postpartum course of a patient with GT who was managed by a multidisciplinary approach that included communication across maternal-fetal medicine, hematology, transfusion medicine, and anesthesiology services. In addition to routine prepartum obstetric imaging and hematologic laboratory studies, we proactively monitored the patient for anti-platelet antibodies every 4-6 weeks to gauge the risk for neonatal alloimmune thrombocytopenia. Furthermore, we prioritized uterotonics, tranexamic acid, and transfusion of HLA-matched platelets to manage bleeding for mother and fetus intrapartum through the postpartum periods. CONCLUSION To date, there are limited guidelines for managing bleeding or preventing alloimmunization during pregnancy in patients with GT. Here, we present a complex case with aggressive management of bleeding prophylactically for the mother while serially monitoring both mother and fetus for peripartum bleeding risks and events. Moreover, future studies warrant continued evaluation of these approaches to mitigate increased bleeding risks in subsequent pregnancies.
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Affiliation(s)
- Matthew M Hernandez
- Department of Pathology, Molecular, and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ayisha Buckley
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Mount Sinai Hospital, Icahn School of Medicine, New York, New York, USA
| | - Ariana Mills
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Mount Sinai Hospital, Icahn School of Medicine, New York, New York, USA
| | - Rachel Meislin
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Mount Sinai Hospital, Icahn School of Medicine, New York, New York, USA
| | - Caroline Cromwell
- Division of Hematology/Oncology, Department of Medicine, Icahn School of Medicine at Mount, New York, New York, USA
| | - Angela Bianco
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Mount Sinai Hospital, Icahn School of Medicine, New York, New York, USA
| | - Noel Strong
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Mount Sinai Hospital, Icahn School of Medicine, New York, New York, USA
| | - Suzanne Arinsburg
- Department of Pathology, Molecular, and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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2
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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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3
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Lawlor CM, Graham ME, Owen LC, Tracy LF. Otolaryngology and the Pregnant Patient. JAMA Otolaryngol Head Neck Surg 2023; 149:930-937. [PMID: 37615978 DOI: 10.1001/jamaoto.2023.2558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
Importance Pregnancy may result in physiologic and pathologic changes in the head and neck. Otolaryngologists may need to intervene medically or surgically with pregnant patients. Careful consideration of risks to both the gravid patient and the developing fetus is vital. Observations Patients may present with otolaryngologic complaints exacerbated by or simply occurring during their pregnancy. Symptoms of hearing loss, vertigo, rhinitis or rhinosinusitis, epistaxis, obstructive sleep apnea, sialorrhea, voice changes, reflux, subglottic stenosis, and benign and malignant tumors of the head and neck may prompt evaluation. While conservative measures are often best, there are medications that are safe for use during pregnancy. When required, surgery for the gravid patient requires a multidisciplinary approach. Conclusions and Relevance Otolaryngologic manifestations in pregnant patients may be managed safely with conservative treatment, medication, and surgery when necessary. Treatment should include consideration of both the pregnant patient and the developing fetus.
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Affiliation(s)
- Claire M Lawlor
- Department of Otolaryngology, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - M Elise Graham
- Department of Otolaryngology-Head and Neck Surgery, London Health Sciences Centre and Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Lynsey C Owen
- Department of Obstetrics and Gynecology, Virginia Hospital Center, Arlington, Virginia
| | - Lauren F Tracy
- Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, Chobanian and Avedisian School of Medicine at Boston University, Boston, Massachusetts
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4
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Okoye HC, Othman M, Nwagha TU, Onwusulu DN, Onoh RC, Chigbu CO. Evaluating the hemostatic effects of tranexamic acid in women with pre-eclampsia. Int J Gynaecol Obstet 2023; 162:931-936. [PMID: 37067045 DOI: 10.1002/ijgo.14779] [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: 10/12/2022] [Revised: 03/11/2023] [Accepted: 03/20/2023] [Indexed: 04/18/2023]
Abstract
OBJECTIVE To evaluate the hemostatic effects of tranexamic acid (TXA) ex vivo in women with pre-eclampsia. METHODS This was an ex vivo study involving 45 normal pregnant women and 45 women with pre-eclampsia (nine with mild and 36 with severe features) matched for age, gestational age, and body mass index. Blood samples were collected and divided into two parts. The first served as the pre-TXA sample, while the second was spiked with TXA and served as the post-TXA sample. Plasma levels of D-dimer and plasmin-antiplasmin complex (PAP) were determined using enzyme-linked immunosorbent assay. RESULTS The mean D-dimer and PAP values in the pre-TXA samples differed significantly between groups. Following spiking with TXA, the mean D-dimer and PAP levels did not differ significantly in the pre-TXA and post-TXA samples (P = 0.560 and P = 0.500, respectively) in the pre-eclampsia cohort. In normal pregnancy, the mean D-dimer and PAP levels in the post-TXA samples did not differ significantly (P = 0.070 and P = 0.050, respectively) from the pre-TXA samples following TXA spiking. CONCLUSION TXA did not significantly affect D-dimer and PAP levels in pre-eclampsia, suggesting that TXA may not increase the thrombotic risks in patients with pre-eclampsia.
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Affiliation(s)
- Helen C Okoye
- Department of Hematology and Immunology College of Medicine, University of Nigeria Ituku-Ozalla campus, Enugu, Nigeria
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, Ontario, Canada
- School of Baccalaureate Nursing, St Lawrence College, Kingston, Ontario, Canada
- Department of Clinical Pathology, School of Medicine, Mansoura University, Mansoura, Egypt
| | - Theresa U Nwagha
- Department of Hematology and Immunology College of Medicine, University of Nigeria Ituku-Ozalla campus, Enugu, Nigeria
| | - Daniel N Onwusulu
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Nnamdi Azikiwe University, Awka, Nigeria
| | - Robinson C Onoh
- Department of Obstetrics and Gynaecology, Alex Ekwueme Federal University Teaching Hospital Abakaliki, Ebonyi, Nigeria
| | - Chibuike O Chigbu
- Department of Obstetrics and Gynaecology, College of Medicine, University of Nigeria Ituku-Ozalla Campus, Enugu, Nigeria
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5
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Liggett MR, Amro A, Son M, Schwulst S. Management of the Pregnant Trauma Patient: A Systematic Literature Review. J Surg Res 2023; 285:187-196. [PMID: 36689816 DOI: 10.1016/j.jss.2022.11.075] [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: 05/05/2022] [Revised: 11/15/2022] [Accepted: 11/16/2022] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Trauma during pregnancy is the leading cause of non-obstetric maternal death and complicates up to 5%-7% of pregnancies. This systematic review without meta-analysis explores the current literature regarding the assessment and management of pregnant trauma patients to provide evidence-based recommendations to guide the general surgeon regarding the prognostic value of laboratory testing including Kleihauer-Betke testing, duration of maternal and fetal monitoring, the use of tranexamic acid, the safety of radiographic studies, and the utility of perimortem cesarean section to improve maternal and fetal mortality. MATERIALS AND METHODS A systematic search of MEDLINE (Ovid), the Cochrane Library (Wiley), and Embase (Elsevier) was performed. The reference lists of included studies were reviewed for relevant citations. RESULTS Of the 45 studies included in this review, there was reasonable evidence to suggest that the minimally injured pregnant trauma patient should be observed for a minimum of 4 h, CT scans to rule out traumatic injury are necessary and safe, perimortem cesarean sections should be performed as soon as maternal cardiac arrest occurs. CONCLUSIONS We recommend delivery by perimortem cesarean section as soon as possible after maternal cardiac arrest, to provide TXA to the hemorrhaging pregnant trauma patient, to obtain trauma CT scans as indicated, and to observe the injured pregnant patient for a minimum of at least 4 h. Additional high-quality studies focusing on the prognostic potential of KB tests and other laboratory studies are needed.
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Affiliation(s)
- Marjorie R Liggett
- Department of General Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Ali Amro
- Department of General Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Moeun Son
- Yale University School of Medicine, Obstetrics, Gynecology & Reproductive Sciences, New Haven, Connecticut
| | - Steven Schwulst
- Department of General Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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6
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Seguin N, Visintini S, Muldoon KA, Walker M. Use of tranexamic acid (TXA) to reduce preterm birth and other adverse obstetrical outcomes among pregnant individuals with placenta previa: a systematic review protocol. BMJ Open 2023; 13:e068892. [PMID: 36882250 PMCID: PMC10008160 DOI: 10.1136/bmjopen-2022-068892] [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] [Indexed: 03/09/2023] Open
Abstract
INTRODUCTION Placenta previa is a placental implantation pathology where the placenta overlies the internal endocervical os. Placenta previa affects approximately 4 per 1000 pregnancies and increases the risk of antepartum bleeding, emergent preterm labour and emergency caesarean sections. Currently, placenta previa is managed through expectant management. Guidelines primarily revolve around the mode and timing of delivery, in-hospital admissions and surveillance. However, the methods to prolong pregnancy have not proven to be clinically effective. Tranexamic acid (TXA), an antifibrinolytic agent, is effectively used to prevent and treat postpartum haemorrhage as well as menorrhagia, with limited adverse effect, and may prove to be an effective treatment for placenta previa. The objective of this systematic review protocol is to review and synthesise the evidence of TXA use for antepartum haemorrhage in placenta previa. METHODS AND ANALYSIS Preliminary searches were conducted on 12 July 2022. We will search MEDLINE, EMBASE, CINAHL, Scopus and the Cochrane Central Register of Controlled Trials. Grey literature resources such as clinical trials registries (ClinicalTrials.gov and the WHO's International Clinical Trials Registry) and preprint servers (Europe PMC and Open Science Framework) will also be searched. The search terms will comprise of index headings and keyword searches related to TXA and the placenta or antepartum bleeding. Cohort and randomised and non-randomised trials will be considered. The target population is pregnant people, of any age, with placenta previa. The intervention is TXA given in the antepartum period. The main outcome of interest is preterm birth before 37 weeks, however, all perinatal outcomes will be collected. Title and abstract will be screened by two reviewers and any conflict will be discussed and evaluated by a third reviewer. The literature will be summarised in narrative form. ETHICS AND DISSEMINATION No ethics approval is required for this protocol. Findings will be disseminated through peer-review publication, lay summaries and conference presentations. PROSPERO REGISTRATION NUMBER CRD42022363009).
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Affiliation(s)
- Niève Seguin
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sarah Visintini
- Berkman Library, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Katherine A Muldoon
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada
| | - Mark Walker
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada
- International and Global Health Office, University of Ottawa, Ottawa, Ontario, Canada
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7
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Malinowski AK, Abdul-Kadir R. Planning Pregnancy and Birth in Women with Inherited Bleeding Disorders. Semin Thromb Hemost 2022; 49:371-381. [PMID: 36368690 DOI: 10.1055/s-0042-1758117] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AbstractInherited bleeding disorders are characterized by a diverse clinical phenotype within and across specific diagnoses. von Willebrand disease (VWD), hemophilia A, and hemophilia B comprise 95 to 97% of inherited bleeding disorders, with the remaining 3 to 5% attributed to rare bleeding disorders, including congenital fibrinogen disorders, factor deficiencies (affecting FII, FV, FV + FVIII, FVII, FX, FXI, and FXIII), and platelet function defects. The pregnancy, birth, and the puerperium may be adversely influenced in the setting of an inherited bleeding disorder depending on its type and clinical phenotype. Obstetric hemostatic challenges may sometimes also unmask the presence of a previously unknown inherited bleeding disorder. This review aims to address the approach to pregnancy and birth in the context of an inherited bleeding disorder and highlights the significance of multidisciplinary input into the care of these women.
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Affiliation(s)
- A. Kinga Malinowski
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Canada
| | - Rezan Abdul-Kadir
- Department of Obstetrics and Gynaecology and Katharine Dormandy Haemophilia and Thrombosis Centre, The Royal Free NHS Foundation Hospital, London, United Kingdom
- Institute for Women's Health, University College London, London, United Kingdom
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8
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HHT-Related Epistaxis and Pregnancy-A Retrospective Survey and Recommendations for Management from an Otorhinolaryngology Perspective. J Clin Med 2022; 11:jcm11082178. [PMID: 35456271 PMCID: PMC9025602 DOI: 10.3390/jcm11082178] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/22/2022] [Accepted: 04/11/2022] [Indexed: 02/07/2023] Open
Abstract
Appropriate management of hereditary hemorrhagic telangiectasia (HHT) is of particular importance in females, as HHT-mediated modifications of the vascular bed and circulation are known to increase the risk of complications during pregnancy and delivery. This study was undertaken to evaluate female HHT patients’ awareness of and experience with HHT during pregnancy and delivery, with a focus on epistaxis. In this retrospective study, 46 females (median age: 60 years) with confirmed HHT completed a 17-item questionnaire assessing knowledge of HHT and its pregnancy-associated complications, the severity of epistaxis during past pregnancies and deliveries, and the desire for better education and counselling regarding HHT and pregnancy. Results revealed that 85% of participants were unaware of their disease status prior to the completion of all pregnancies. Further, 91% reported no knowledge of increased pregnancy-related risk due to HHT. In regard to epistaxis, 61% of respondents reported experiencing nosebleeds during pregnancy. Finally, approximately a third of respondents suggested that receiving counseling on the risks of HHT in pregnancy could have been helpful. Findings suggest that awareness of HHT and its potential for increasing pregnancy-related risk is poor. Best practices in HHT management should be followed to minimize negative effects of the disorder.
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9
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Shalaby MA, Maged AM, Al-Asmar A, El Mahy M, Al-Mohamady M, Rund NMA. Safety and efficacy of preoperative tranexamic acid in reducing intraoperative and postoperative blood loss in high-risk women undergoing cesarean delivery: a randomized controlled trial. BMC Pregnancy Childbirth 2022; 22:201. [PMID: 35287618 PMCID: PMC8919531 DOI: 10.1186/s12884-022-04530-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 02/21/2022] [Indexed: 11/10/2022] Open
Abstract
Background Objective to assess the value of preoperative tranexamic acid (TXA) in reduction of intraoperative and postoperative blood loss in high-risk cesarean delivery (CD). Methods A double blind randomized controlled trial included 160 high risk women who underwent elective lower segment CD. They were equally randomized to receive either 1 g of TXA or placebo 15 min before surgery. The primary outcome was Intraoperative blood loss. Results The estimated blood loss was significantly higher in the placebo group when compared to TXA group (896.81 ± 519.6 vs. 583.23 ± 379.62 ml, P < 0.001). Both postoperative hemoglobin and hematocrit were lower (9.2 ± 1.6 and 27.4 ± 4.1 vs. 10.1 ± 1.2 and 30.1 ± 3.4, P values < 0.001and 0.012 respectively) and their change percentages (15.41 vs. 7.11%, P < 0.001) were higher in the placebo group when compared to TXA one. The need for further ecbolics was higher in placebo group when compared to TXA group (46.25 vs. 13.75%, P < 0.001). Conclusion Preoperative TXA is safe and effective in reducing blood loss during and after high-risk CD. Trial registration ClincalTrial.gov ID: NCT03820206.
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Affiliation(s)
- Mohamed A Shalaby
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, 366 Fardos gardens, 6 October, Giza, 12543, Egypt.
| | - Ahmed M Maged
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, 366 Fardos gardens, 6 October, Giza, 12543, Egypt
| | - Amira Al-Asmar
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, 366 Fardos gardens, 6 October, Giza, 12543, Egypt
| | - Mohamed El Mahy
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, 366 Fardos gardens, 6 October, Giza, 12543, Egypt
| | - Maged Al-Mohamady
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, 366 Fardos gardens, 6 October, Giza, 12543, Egypt
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10
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Miller EC. Maternal Stroke Associated With Pregnancy. Continuum (Minneap Minn) 2022; 28:93-121. [PMID: 35133313 PMCID: PMC10101187 DOI: 10.1212/con.0000000000001078] [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] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article summarizes current knowledge of the epidemiology, pathophysiology, prevention, and treatment of cerebrovascular disease in pregnant and postpartum women. RECENT FINDINGS Stroke is a leading cause of maternal morbidity and mortality, and most fatal strokes are preventable. Adaptive physiologic changes of pregnancy, including hemodynamic changes, venous stasis, hypercoagulability, and immunomodulation, contribute to increased maternal stroke risk. The highest-risk time period for maternal stroke is the immediate postpartum period. Migraine and hypertensive disorders of pregnancy, including gestational hypertension and preeclampsia, are major risk factors for maternal stroke. Adverse pregnancy outcomes, including gestational hypertension, preeclampsia, preterm delivery, and fetal growth restriction, are important risk factors for cerebrovascular disease later in life. SUMMARY Many catastrophic maternal strokes could be avoided with targeted prevention efforts, early recognition of warning signs, and rapid evaluation of neurologic symptoms. Neurologists play a central role in the care of pregnant patients with cerebrovascular disease, whether acute or chronic, and should be familiar with the unique and complex physiology of pregnancy and its complications, particularly hypertensive disorders of pregnancy.
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Binyamin Y, Orbach-Zinger S, Gruzman I, Frenkel A, Lerman S, Zlotnik A, Frank D, Ioscovich A, Erez O, Heesen M. The effect of prophylactic use of tranexamic acid for cesarean section. J Matern Fetal Neonatal Med 2022; 35:9157-9162. [DOI: 10.1080/14767058.2021.2019215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Yair Binyamin
- Department of Anesthesiology, Soroka University Medical Center, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Sharon Orbach-Zinger
- Department of Anesthesia, Beilinson Hospital, Rabin Medical Center associated with Sakler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Igor Gruzman
- Department of Anesthesiology, Soroka University Medical Center, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Amit Frenkel
- Department of Anesthesiology, Soroka University Medical Center, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Sofia Lerman
- Department of Anesthesiology, Soroka University Medical Center, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Alexander Zlotnik
- Department of Anesthesiology, Soroka University Medical Center, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Dmitry Frank
- Department of Anesthesiology, Soroka University Medical Center, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Alexander Ioscovich
- Department of Anesthesiology, Perioperative Medicine and Pain Treatment, Shaare Zedek Medical Center, Hebrew University Hadassah Medical School, Jerusalem, Israel
| | - Offer Erez
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Maternity Department “D”, Division of Obstetrics and Gynecology, Soroka University Medical Center, Beer-Sheva, Israel
- Department of Obstetrics and Gynecology, Hutzel Women’s Hospital, School of Medicine, Wayne State University, Detroit, MI, USA
| | - Michael Heesen
- Department of Anesthesia, Kantonsspital Baden, Baden, Switzerland
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12
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Hurskainen T, Deng MX, Etherington C, Burns JK, Martin Calderon L, Moher D, Edwards W, Boet S. Tranexamic acid for prevention of bleeding in cesarean delivery: An overview of systematic reviews. Acta Anaesthesiol Scand 2022; 66:3-16. [PMID: 34514595 DOI: 10.1111/aas.13981] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 08/20/2021] [Accepted: 08/24/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Bleeding is the leading cause of maternal mortality in the world. Tranexamic acid reduces bleeding in trauma and surgery. Several systematic reviews of randomized trials have investigated tranexamic acid in the prevention of bleeding in cesarean delivery. However, the conclusions from systematic reviews are conflicting. This overview aims to summarize the evidence and explore the reasons for conflicting conclusions across the systematic reviews. METHODS A comprehensive literature search of Medline, Embase, and Cochrane Database of Systematic Reviews was conducted from inception to April 2021. Screening, data extraction, and quality assessments were performed by two independent reviewers. A Measurement Tool to Assess Reviews 2 and the Risk of Bias Assessment Tool for Systematic Reviews were used for study appraisal. A qualitative synthesis of evidence is presented. RESULTS In all, 14 systematic reviews were included in our analysis. Across these reviews, there were 32 relevant randomized trials. A modest reduction in blood transfusions and bleeding outcomes was found by most systematic reviews. Overall confidence in results varied from low to critically low. All of the included systematic reviews were at high risk of bias. Quality of evidence from randomized trials was uncertain. CONCLUSIONS Systematic reviews investigating prophylactic tranexamic acid in cesarean delivery are heterogeneous in terms of methodological and reporting quality. Tranexamic acid may reduce blood transfusion and bleeding outcomes, but rigorous well-designed research is needed due to the limitations of the included studies. Data on safety and adverse effects are insufficient to draw conclusions.
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Affiliation(s)
- Tomi Hurskainen
- Department of Anesthesiology The Ottawa HospitalUniversity of Ottawa Ottawa Ontario Canada
- Division of Anesthesiology Department of Anesthesiology, Intensive Care and Pain Medicine Helsinki University Hospital Helsinki Finland
| | - Mimi X. Deng
- School of Medicine University of Ottawa Ottawa Ontario Canada
| | - Cole Etherington
- Ottawa Hospital Research Institute – Centre for Practice Changing Research Ottawa Ontario Canada
| | - Joseph K. Burns
- Clinical Research Assistant Clinical Epidemiology Program Ottawa Hospital Research Institute Ottawa Ontario Canada
| | | | - David Moher
- Knowledge Synthesis Group Clinical Epidemiology Program Ottawa Hospital Research Institute Ottawa Ontario Canada
- School of Epidemiology and Public Health University of Ottawa Ottawa Ontario Canada
| | - Wesley Edwards
- Department of Anesthesia and Pain Medicine The Ottawa Hospital Ottawa Ontario Canada
- Faculty of Medicine University of Ottawa Ottawa Ontario Canada
| | - Sylvain Boet
- Department of Anesthesiology and Pain Medicine The Ottawa Hospital Research InstituteThe Ottawa HospitalGeneral Campus Ottawa Ontario Canada
- Department of Innovation in Medical Education The Ottawa Hospital Research InstituteThe Ottawa HospitalGeneral Campus Ottawa Ontario Canada
- Faculty of Medicine Francophone Affairs Ottawa Ontario Canada
- Institut du savoir Montfort Ottawa Ontario Canada
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13
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Hereditary Angioedema in Pregnancy. Obstet Gynecol Surv 2021; 76:566-574. [PMID: 34586422 DOI: 10.1097/ogx.0000000000000941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Importance Hereditary angioedema is a rare disease of potentially life-threatening attacks of angioedema that can affect patients of all ages, including women of childbearing age. Pregnancy can affect the course of the disease and the choice of treatment used. It is important for the care providers to recognize this disease and understand its mechanism in order to provide appropriate care for the patients. Objective The goal of this article is to provide an overview of hereditary angioedema and guideline for management of pregnant patients with hereditary angioedema. Evidence Acquisition A search of the available English language literature was performed on PubMed and Ovid MEDLINE using the key words hereditary angioedema and pregnancy. Additional articles were selected from the reference lists of the reviewed articles. Results The data for hereditary angioedema in pregnant patients come from observational studies, case reports, retrospective reviews, and questionnaires. The course of hereditary angioedema can be variable between different patients and pregnancies. Plasma-derived C1 inhibitor concentrate is both safe and effective as treatment for attacks and as preventive therapy in pregnancy. With proper recognition, understanding of the disease, and appropriate medical management, most patients will undergo successful pregnancy and delivery. Conclusions and Relevance Clinicians should maintain high suspicion for this disease when patients present with recurrent episodes of angioedema without urticaria or severe abdominal pains of unclear etiology. Treatment plans during pregnancy and delivery should be individualized, and the patient's care should be shared by a clinician experienced in the management of this disease.
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Arribas M, Roberts I, Chaudhri R, Geer A, Prowse D, Lubeya MK, Kayani A, Javaid K, Grassin-Delyle S, Shakur-Still H. WOMAN-PharmacoTXA trial: Study protocol for a randomised controlled trial to assess the pharmacokinetics and pharmacodynamics of intramuscular, intravenous and oral administration of tranexamic acid in women giving birth by caesarean section. Wellcome Open Res 2021; 6:157. [PMID: 34250266 PMCID: PMC8264807 DOI: 10.12688/wellcomeopenres.16884.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Intravenous tranexamic acid (TXA) within 3 hours of birth significantly reduces death due to bleeding in women with postpartum haemorrhage (PPH). Most PPH deaths occur in the first hours after giving birth and treatment delay decreases survival. One barrier to rapid TXA treatment is the need for intravenous injection. Intramuscular injection and oral solution of TXA would be easier and faster to administer and would require less training. However, the pharmacokinetics (PK), pharmacodynamics and safety of TXA administered by different routes in pregnant women have not been established. The main aim of this study is to ascertain whether IM and oral solution of TXA will be absorbed at levels sufficient to inhibit fibrinolysis in pregnant women. Methods: WOMAN-PharmacoTXA is a prospective, randomised, open label trial to be conducted in Zambia and Pakistan. Adult women undergoing caesarean section with at least one risk factor for PPH will be included. Women will be randomised to receive one of the following about 1 hour prior to caesarean section: 1-gram TXA IV, 1-gram TXA IM, 4-grams TXA oral solution or no TXA. Randomisation will continue until 120 participants with at least six post randomisation PK samples are included. TXA concentration in maternal blood samples will be measured at baseline and at different time points during 24 hours after receipt of intervention. Blood TXA concentration will be measured from the umbilical cord and neonate. The primary endpoint is maternal blood TXA concentrations over time. Secondary outcomes include umbilical cord and neonate TXA concentration D-dimer concentration, blood loss and clinical diagnosis of PPH, injection site reactions and maternal and neonate adverse events. Discussion: The WOMAN-PharmacoTXA trial will provide important data on pharmacokinetics, pharmacodynamics and safety of TXA after IV, intramuscular and oral administration in women giving birth by caesarean section. Trial registration: ClincalTrials.gov,
NCT04274335 (18/02/2020).
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Affiliation(s)
- Monica Arribas
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Rizwana Chaudhri
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, H-8, Pakistan
| | - Amber Geer
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Danielle Prowse
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Mwansa Ketty Lubeya
- Women and Newborn Hospital, University Teaching Hospital, Nationalist Road, Lusaka, PB RW1X, Zambia.,Department of Obstetrics and Gynaecology, The University of Zambia-School of Medicine, Lusaka, Zambia
| | - Aasia Kayani
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, H-8, Pakistan
| | - Kiran Javaid
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, H-8, Pakistan
| | - Stanislas Grassin-Delyle
- Département de Biotechnologie de la Santé, Université Paris-Saclay, UVSQ, Inserm, Infection et inflammation, Montigny le Bretonneux, France.,Département des Maladies des Voies Respiratoires, Hôpital Foch, Suresnes, France
| | - Haleema Shakur-Still
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
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15
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Kashanian M, Dadkhah F, Tabatabaei N, Sheikhansari N. Effects of tranexamic acid on the amount of bleeding following vaginal delivery and its adverse effects: a double-blind placebo controlled randomized clinical trial. J Matern Fetal Neonatal Med 2021; 35:5611-5615. [PMID: 34024233 DOI: 10.1080/14767058.2021.1888911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
INTRODUCTION Postpartum hemorrhage (PPH) is the most important concern after delivery. Tranexamic acid (TXA), an anti-fibrinolytic agent, has been suggested for prevention and treatment of PPH. OBJECTIVE The purpose of the present study was to find the effects of TXA on the amount of bleeding following vaginal delivery and its adverse effects. MATERIALS AND METHODS The study was performed as a randomized double blind placebo controlled clinical trial on low risk pregnant women who delivered vaginally. The patients were randomly assigned into two groups. Women in the intervention group received 10 mg/kg infusion of TXA in 100 mL normal saline and the control group received one vial of distilled water (as placebo) in 100 mL normal saline. The primary outcome was amount of bleeding after delivery. The secondary outcomes were decreased in hemoglobin level, need for additional uterotonic agents and need for blood transfusion. All were evaluated 6 h after delivery and compared in the two groups. Participants were followed up to six weeks after delivery for any TXA side effects. RESULTS Two hundred and seven women finished the study. There were no significant differences between the two groups in terms of demographic data and risk factors for bleeding. Mean blood loss and need to misoprostol was more in the control group (p=.033 and p=.000, respectively). Hemoglobin level was higher in the TXA group 6 h after delivery. None of the subjects needed blood transfusion, uterine balloon tamponade or emergency hysterectomy. Adverse effects were higher in the TXA group, however, there were no side effects between weeks 3 and 6 in both groups. There were no thromboembolic events during six weeks after delivery. CONCLUSIONS Tranexamic acid can reduce the amount of bleeding after vaginal delivery in low risk women without having serious complications. Also, it may decrease the need for additional uterotonic agents. Trial registration number and registry website: IRCT20091023002624N22.
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Affiliation(s)
- Maryam Kashanian
- Department of Obstetrics & Gynecology, Akbarabadi Teaching Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Farideh Dadkhah
- Department of Obstetrics & Gynecology, Firoozgar Teaching Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Nasim Tabatabaei
- Department of Obstetrics & Gynecology, Akbarabadi Teaching Hospital, Iran University of Medical Sciences, Tehran, Iran
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16
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Complexation of chromium (III) with the antifibrinolytic drug tranexamic acid: Formation, kinetics, and molecular modeling studies. J Mol Liq 2021. [DOI: 10.1016/j.molliq.2021.115513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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17
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Byrne B, Ryan K, Lavin M. Current Challenges in the Peripartum Management of Women with von Willebrand Disease. Semin Thromb Hemost 2021; 47:217-228. [PMID: 33636752 DOI: 10.1055/s-0041-1723797] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
For many women, pregnancy and childbirth represent their first major hemostatic challenges. Despite advancements in obstetric care, up to 2 to 5% of all deliveries are complicated by postpartum hemorrhage (PPH). To mitigate bleeding risk, physiological changes occur in pregnancy, including increases in plasma von Willebrand factor (VWF) and factor VIII levels. For women with von Willebrand disease (VWD), these physiological alterations are blunted or absent. As a result, women with VWD have a heightened risk of PPH, both primary (in the first 24 hours) and secondary (>24 hours to 6 to 12 weeks postpartum). Pregnancy and delivery management for women with VWD should therefore be carefully coordinated as part of a multidisciplinary team approach. In the absence of large-scale clinical trials, the management of women with VWD during pregnancy is guided by expert consensus guidelines. Clinical practices internationally are not uniform, and areas of considerable clinical uncertainty exist. Traditional peripartum plasma VWF thresholds for hemostatic cover and therapeutic targets are currently under scrutiny, as PPH is not eliminated in women with VWD who receive replacement therapy. The benefit and optimal duration of postpartum tranexamic acid have yet to be defined, and standardized methods of quantification of blood loss at the time of delivery are currently lacking. In this article, we review the evidence base to date and explore the current clinical challenges in the management of pregnant women with VWD.
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Affiliation(s)
- Bridgette Byrne
- Department of Obstetrics & Gynaecology, Coombe Women and Infants University Hospital, Dublin, Ireland.,Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Kevin Ryan
- Department of Obstetrics & Gynaecology, Coombe Women and Infants University Hospital, Dublin, Ireland.,National Coagulation Centre, St. James' Hospital, Dublin, Ireland
| | - Michelle Lavin
- National Coagulation Centre, St. James' Hospital, Dublin, Ireland.,Irish Centre for Vascular Biology, School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
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18
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Zhou C, Zhang L, Bao Y, Li L, Zhang T, Zhang X, Wang C. Effect of blood transfusion during cesarean section on postpartum hemorrhage in a tertiary hospital over a 4-year period. Medicine (Baltimore) 2021; 100:e23885. [PMID: 33545955 PMCID: PMC7837845 DOI: 10.1097/md.0000000000023885] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/24/2020] [Indexed: 11/25/2022] Open
Abstract
Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and death worldwide. The history of cesarean section and the occurrence of placenta previa were significantly associated with the increase in blood transfusion. Therefore, to prevent PPH, it is important to understand the effect of blood transfusion during cesarean section on postpartum hemorrhage. The purpose of this study is to determine the cause of blood transfusion during cesarean section, especially large amounts of blood transfusion, and to take measures to reduce the blood demand caused by PPH with limited blood supply.This study was a retrospective study of patients who underwent blood transfusion during cesarean section in Qilu Hospital of Shandong University (China) from January 2013 to December 2016. Red blood cell infusion ≥10 U during cesarean section was defined as massive blood transfusion. The study collected the demographics of pregnant women, obstetric characteristics and reasons for blood transfusions, as well as blood components and blood transfusion results. Multivariate regression analysis was performed for evaluating the risk factors of PPN.From 2013 to 2016, a total of 587 patients received blood transfusions during cesarean section. The proportion of women receiving blood transfusion during cesarean section increased (from 3.21% to 7.40%, P < .001). The history of cesarean section (P = .005) and the occurrence of placenta previa were positively correlated with the increase in blood transfusion (P = .016). There were 72 cases of massive blood transfusion, accounting for 12.27% of blood transfusion patients. Among mass blood transfusions, 93.1% of cases had prior cesarean delivery, and placenta previa accounted for 95.8%. 19.4% of patients receiving massive blood transfusions underwent hysterectomy. There was no significant difference in maternal BMI and gestational age between the mass blood transfusion group and the non-mass blood transfusion group.From 2013 to 2016, the demand for blood transfusion, especially the demand for massive blood transfusion, increased. Repeated cesarean section and placental previa combined with uterine scar are positively correlated with increased blood transfusion. Reducing the initial cesarean section should help reduce the massive blood transfusion caused by placenta previa with a history of cesarean section.
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19
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Herbert K, Buchbinder L, Seshachellam V, Lee L. Resuscitative Endovascular Balloon Occlusion of the Aorta and Concomitant Tranexamic Acid for Cesarean Hysterectomy Complicated by Common Femoral Artery Thrombosis: A Case Report. Cureus 2020; 12:e11197. [PMID: 33269128 PMCID: PMC7704019 DOI: 10.7759/cureus.11197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2020] [Indexed: 11/06/2022] Open
Abstract
With increasing cesarean delivery rates, placenta accreta spectrum (PAS) disorders are occurring more frequently and represent a significant cause of peripartum hemorrhage. Different modalities have been explored to control blood loss during cesarean hysterectomies for PAS disorders, including administration of tranexamic acid (TXA) and balloon occlusion strategies. We present a case of a cesarean hysterectomy for a placenta percreta with the use of TXA and arterial balloon occlusion complicated by a lower extremity arterial thrombus requiring emergent thrombectomy. The outcome of this case suggests using caution with concomitant use of TXA and arterial balloon occlusion.
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Affiliation(s)
- Katherine Herbert
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, USA
| | - Lindsey Buchbinder
- Department of Anesthesiology, McGovern Medical School University of Texas Health Science Center, Houston, USA
| | - Vishwas Seshachellam
- Department of Anesthesiology, McGovern Medical School University of Texas Health Science Center, Houston, USA
| | - Linden Lee
- Department of Anesthesiology, McGovern Medical School University of Texas Health Science Center, Houston, USA
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20
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Myomectomy associated blood transfusion risk and morbidity after surgery. Fertil Steril 2020; 114:175-184. [PMID: 32532486 DOI: 10.1016/j.fertnstert.2020.02.110] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 02/24/2020] [Accepted: 02/25/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate blood transfusion risks and the associated 30-day postoperative morbidity after myomectomy. DESIGN Retrospective cohort study. SETTING Not applicable. PATIENT(S) Women who underwent myomectomies for symptomatic uterine fibroids (N = 3,407). INTERVENTION(S) Blood transfusion during or within 72 hours after myomectomy. MAIN OUTCOME MEASURE(S) The primary outcomes were rate of blood transfusion with myomectomy and risk factors associated with receiving a transfusion. The secondary outcome was 30-day morbidity after myomectomy. RESULT(S) The overall rate of blood transfusion was 10% (hysteroscopy, 6.7%; laparoscopy, 2.7%; open/abdominal procedures, 16.4%). Independent risk factors for transfusion included as follows: black race (adjusted odds ratio [aOR] 2.27, 95% confidence interval [CI] 1.62-3.17) and other race (aOR 1.77, 95% CI 1.20-2.63) compared with white race; preoperative hematocrit <30% compared to ≥30% (aOR 6.41, 95% CI 4.45-9.23); preoperative blood transfusion (aOR 2.81, 95% CI 1.46-5.40); high fibroid burden (aOR 1.91, 95% CI 1.45-2.51); prolonged surgical time (fourth quartile vs. first quartile aOR 11.55, 95% CI 7.05-18.93); and open/abdominal approach (open/abdominal vs. laparoscopic aOR 9.06, 95% CI 6.10-13.47). Even after adjusting for confounders, women who required blood transfusions had an approximately threefold increased risk for experiencing a major postoperative complication (aOR 2.69, 95% CI 1.58-4.57). CONCLUSION(S) Analysis of a large multicenter database suggests that the overall risk of blood transfusion with myomectomy is 10% and is associated with an increased 30-day postoperative morbidity. Preoperative screening of women at high risk for transfusion is prudent as perioperative transfusion itself leads to increased major postoperative complications.
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21
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Park H, Lee H, Seo C, Min J, Ji M, Kim Y, Choi S, Kim D, Kim JD, Jeong DH, Lee W, Paik M. Tranexamic Acid Analysis as Ethoxycarbonyl‐
tert
‐butyldimethylsilyl Derivatives by Gas Chromatography–Tandem Mass Spectrometry. B KOREAN CHEM SOC 2020. [DOI: 10.1002/bkcs.11977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Hyung‐Jin Park
- Department of Physiology and Department of Biomedical SciencesAjou University School of Medicine Suwon Republic of Korea
| | - Hyeon‐Seong Lee
- College of PharmacySunchon National University Suncheon Republic of Korea
| | - Chan Seo
- College of PharmacySunchon National University Suncheon Republic of Korea
| | - Jeuk Min
- College of PharmacySunchon National University Suncheon Republic of Korea
| | - Moongi Ji
- College of PharmacySunchon National University Suncheon Republic of Korea
| | - Youngbae Kim
- College of PharmacySunchon National University Suncheon Republic of Korea
| | - Subin Choi
- Redone TechLaboratories of Marine New Drugs Seoul Republic of Korea
| | - Doo‐Young Kim
- College of PharmacySunchon National University Suncheon Republic of Korea
- Hyundai PharmNew Drug Discovery Lab Yongin Republic of Korea
| | - Jung Dong Kim
- RaphasAvison Biomedical Research Center Seoul Republic of Korea
| | - Do Hyeon Jeong
- RaphasAvison Biomedical Research Center Seoul Republic of Korea
| | - Wonjae Lee
- College of PharmacyChosun University Gwangju Republic of Korea
| | - Man‐Jeong Paik
- College of PharmacySunchon National University Suncheon Republic of Korea
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22
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Xia Y, Griffiths BB, Xue Q. Tranexamic acid for postpartum hemorrhage prevention in vaginal delivery: A meta-analysis. Medicine (Baltimore) 2020; 99:e18792. [PMID: 32011478 PMCID: PMC7220439 DOI: 10.1097/md.0000000000018792] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 12/09/2019] [Accepted: 12/13/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Tranexamic acid (TA) has been demonstrated to reduce blood loss and the incidences of postpartum hemorrhage (PPH) during caesarean sections. We compared the clinical efficacy of TA administration on vaginal deliveries with recently published papers. METHODS Electronic databases of PubMed, Cochrane Library, Embase and Chinese CNKI (Chinese database) and Wanfang were searched through November 2019.The randomized controlled trials were selected between TA and control groups. The relevant studies included four trials with a total of 4579 patients. RESULTS Patients treated with TA had a reduction in total blood loss (P = .009), lower postoperative blood loss (P < .00001), a reduced number of PPH (P = .02). However, the occurrence of nausea or/and vomiting is higher in the TA group (the incidence of nausea or vomiting [P < .00001], nausea [P < .00001] and vomiting [P < .00001]). CONCLUSION TA resulted in fewer occurrence rates of PPH, and no significant increase in occurrences of dizziness or photopsia, but higher incidence of vomiting and nausea.
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Affiliation(s)
- Yimeng Xia
- Department of Anaesthesiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Brian B Griffiths
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - QingSheng Xue
- Department of Anaesthesiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
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23
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Ibrahim TH. Efficacy of tranexamic acid in reducing blood loss, blood and blood products requirements in Cesarian sections for patients with placenta accreta. ACTA ACUST UNITED AC 2019. [DOI: 10.1186/s42077-019-0051-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Placenta accreta is an obstetric emergency and the main cause of maternal morbidity and mortality due to the associated bleeding and coagulopathy. Tranexamic acid has been widely used to decrease blood loss in trauma patients and patients with postpartum hemorrhage. We aimed at studying the effect of tranexamic acid in reducing blood loss and blood transfusion in patients with placenta accreta.
Methods
In a double-blinded randomized controlled study, 46 patients were recruited and divided into two groups, Group A is the tranexamic group where patients received 10 mg/kg tranexamic acid after cord clamping and continued on tranexamic infusion 10 mg/kg/h till the end of the surgery. Group B is the placebo where patients received normal saline instead. Primary outcome was the amount of intraoperative blood loss, and other outcomes included the number of blood and blood products transfused intraoperative and in the first 24 h postoperative, the immediate postoperative Hb level, platelet count, and coagulation profile. Data were collected, coded, tabulated, and then analyzed using Minitab® 16.1.0 statistics software package. Variables were presented as mean and standard deviation and analyzed using unpaired t test. Any difference with p value < 0.05 was considered statistically significant.
Results
Amount of intraoperative blood loss was significantly less in the tranexamic group 2232 ± 1204 ml compared to the placebo group 3405 ± 1193 ml (p value 0.002), and patients in the tranexamic group received less units of packed red blood cells, fresh frozen plasma, and platelets compared to those in the placebo group (4.2 ± 1.9 vs 6.1 ± 2.2 with p value 0.003, 3.4 ± 1.3 vs 4.2 ± 1.2 with P value 0.036 and 4.8 ± 2.1 vs 6.2 ± 2.4 with p value 0.041, respectively). There was no statistically significant difference in the first postoperative Hb level, platelet count, and coagulation profile between the two groups; however, the amount of blood and products transfused in the first 24 h postoperative were significantly less in the tranexamic group
Conclusion
Tranexamic acid infusion was effective in reducing intraoperative blood loss and intraoperative and postoperative blood and blood products’ transfusion.
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Abdul IF, Amadu MB, Adesina KT, Olarinoye AO, Omokanye LO. Adjunctive use of tranexamic acid to tourniquet in reducing haemorrhage during abdominal myomectomy - A randomized controlled trial. Eur J Obstet Gynecol Reprod Biol 2019; 242:150-158. [PMID: 31600715 DOI: 10.1016/j.ejogrb.2019.09.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 08/12/2019] [Accepted: 09/18/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Uterine fibroids are the commonest tumour of the female genital tract; about one third are symptomatic and require management. The treatment of uterine fibroids may be medical, surgical, conservative or expectant. Myomectomy is the common surgical treatment option for women failing medical management and desiring to preserve fertility and/or their uterus. The tourniquet is shown to be effective in reducing blood loss during myomectomy and tranexamic to a less extent. However, the adjunctive use of tranexamic acid with tourniquet to further reduce blood loss has not been studied. AIM The aim of the study was to determine the efficacy of perioperative intravenous tranexamic acid in further reducing blood loss at abdominal myomectomy when used as an adjunct to tourniquet. METHODS The study was a randomized double-blind controlled study involving women who underwent abdominal myomectomy. Participants were randomized to either tourniquet plus intravenous tranexamic acid or tourniquet plus placebo groups using simple random sampling. The primary outcomes were the intra-operative blood loss, post-operative haematocrit values and need for intra-operative blood transfusion. The data was analyzed using the SPSS software version 23.0 and p value < 0.05 was significant. RESULTS The mean intra-operative blood loss (998.72 ± 607.21 ml vs 907.25 ± 529.85 ml, p = 0.475), intra-operative blood transfusion rate (45% vs. 30%; p = 0.166) and mean unit of blood transfused (1.13 ± 1.64 vs. 0.75 ± 1.28; p = 0.256) were higher for tourniquet plus placebo group compared to tourniquet plus tranexamic acid group. The estimated blood loss per 100 g of fibroid removed was reduced significantly in the tranexamic acid plus tourniquet group (139.80 ± 2.28 ml vs 104.09 ± 1.97 ml; p = 0.001). STRENGTH AND LIMITATIONS The strength of the study include randomization and blinding. The limitations included non-uniformity of sizes and locations of fibroids, as well as the different surgeons with possibly different skills, techniques and experiences, though they were statistically not significant. CONCLUSION The adjunctive use of tranexamic acid to tourniquet significantly further reduces intraoperative blood loss during abdominal myomectomy when compared to tourniquet alone. RECOMMENDATIONS Adjunctive use of tranexamic acid is recommended for further reducing intra-operative blood loss during abdominal myomectomy.
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Affiliation(s)
- Ishaq F Abdul
- Department of Obstetrics and Gynaecology, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria.
| | - Motunrayo B Amadu
- Department of Obstetrics and Gynaecology, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria
| | - Kike T Adesina
- Department of Obstetrics and Gynaecology, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria
| | - Adebunmi O Olarinoye
- Department of Obstetrics and Gynaecology, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria
| | - Lukman O Omokanye
- Department of Obstetrics and Gynaecology, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria
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Miyata S, Itakura A, Ueda Y, Usui A, Okita Y, Ohnishi Y, Katori N, Kushimoto S, Sasaki H, Shimizu H, Nishimura K, Nishiwaki K, Matsushita T, Ogawa S, Kino S, Kubo T, Saito N, Tanaka H, Tamura T, Nakai M, Fujii S, Maeda T, Maeda H, Makino S, Matsunaga S. TRANSFUSION GUIDELINES FOR PATIENTS WITH MASSIVE BLEEDING. ACTA ACUST UNITED AC 2019. [DOI: 10.3925/jjtc.65.21] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Shigeki Miyata
- Department of Clinical Laboratory Medicine, National Cerebral and Cardiovascular Center
| | - Atsuo Itakura
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University
| | - Yuichi Ueda
- Nara Prefectural Hospital Organization, Nara Prefecture General Medical Center
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Kobe University
| | - Yoshihiko Ohnishi
- Operation Room, Anesthesiology, National Cerebral and Cardiovascular Center
| | - Nobuyuki Katori
- Department of Anesthesiology, Keio University School of Medicine
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine
| | - Hiroaki Sasaki
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | | | - Kunihiro Nishimura
- Department of Statistics and Data Analysis, Dept of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center
| | | | | | - Satoru Ogawa
- Department of Anesthesiology, Kyoto Prefectural University of Medicine
| | | | | | - Nobuyuki Saito
- Shock and Trauma Center, Nippon Medical School Chiba Hokusoh Hospital
| | - Hiroshi Tanaka
- Department of Surgery, Division of Minimum Invasive Surgery, Kobe University
| | | | - Michikazu Nakai
- Department of Statistics and Data Analysis, Dept of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center
| | - Satoshi Fujii
- Department of Laboratory Medicine, Asahikawa Medical University
| | - Takuma Maeda
- Division of Transfusion Medicine, National Cerebral and Cardiovascular Center
| | - Hiroo Maeda
- Transfusion Medicine and Cell Therapy, Saitama Medical Center/Saitama Medical University
| | - Shintaro Makino
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University
| | - Shigetaka Matsunaga
- Department of Obstetrics and Gynecology, Saitama Medical Center/Saitama Medical University
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Feray S, Fain O, Kayem G, Sabourdin N, Constant I, Rigouzzo A. Repeated attacks of type III hereditary angioedema with factor XII mutation during pregnancy. Int J Obstet Anesth 2018; 36:114-118. [DOI: 10.1016/j.ijoa.2018.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 07/17/2018] [Accepted: 07/27/2018] [Indexed: 11/24/2022]
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Colucci G, Helsing K, Biasiutti FD, Raio L, Schmid P, Tsakiris DA, Eberle B, Surbek D, Lämmle B, Alberio L. Standardized Management Protocol in Severe Postpartum Hemorrhage: A Single-Center Study. Clin Appl Thromb Hemost 2018; 24:884-893. [PMID: 29669438 PMCID: PMC6714733 DOI: 10.1177/1076029618758956] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Severe postpartum hemorrhage (sPPH) is an obstetric emergency that needs prompt and effective therapy to reduce the risk of complications. In this study, women who developed sPPH (study cohort, n = 27) were treated according to a standardized management protocol prescribing sequential administration of uterotonic drugs, crystalloids, tranexamic acid, labile blood products, low-dose fibrinogen, and recombinant activated factor VII (rFVIIa). This group was compared to patients treated with different strategies during 2 preceding periods: an in-house guideline regulating the administration of rFVIIa (historical cohort 1, n = 20) and no specific guideline (historical cohort 2, n = 27). The management protocol was used over 33 months. The study cohort had a lower estimated blood loss (P = .004) and required less red blood cell concentrates (P = .007), fresh frozen plasma units (P = .004), and platelet concentrates (P = .020) compared to historical cohort 1 and historical cohort 2, respectively. The necessity of emergency postpartum hysterectomy was lower in the study group (P = .012). In conclusion, in patients with sPPH treated with this standardized management protocol, we observed a decreased requirement of labile blood products and lower need to proceed to emergency postpartum hysterectomy.
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Affiliation(s)
- Giuseppe Colucci
- 1 Department of Hematology and Central Hematology Laboratory, University Hospital and University of Bern, Bern, Switzerland.,2 Service of Hematology, Clinica Luganese Moncucco, Lugano, Switzerland
| | - Karin Helsing
- 1 Department of Hematology and Central Hematology Laboratory, University Hospital and University of Bern, Bern, Switzerland
| | - Franziska Demarmels Biasiutti
- 1 Department of Hematology and Central Hematology Laboratory, University Hospital and University of Bern, Bern, Switzerland
| | - Luigi Raio
- 3 Department of Obstetrics and Gynecology, University Hospital and University of Bern, Bern, Switzerland
| | - Pirmin Schmid
- 1 Department of Hematology and Central Hematology Laboratory, University Hospital and University of Bern, Bern, Switzerland
| | | | - Balthasar Eberle
- 5 Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Daniel Surbek
- 3 Department of Obstetrics and Gynecology, University Hospital and University of Bern, Bern, Switzerland
| | - Bernhard Lämmle
- 1 Department of Hematology and Central Hematology Laboratory, University Hospital and University of Bern, Bern, Switzerland.,6 Center for Thrombosis and Hemostasis, University Medical Center, Mainz, Germany
| | - Lorenzo Alberio
- 1 Department of Hematology and Central Hematology Laboratory, University Hospital and University of Bern, Bern, Switzerland.,7 Service et laboratoire central d'hématologie, CHUV, University Hospital of Lausanne, Lausanne, Switzerland
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Shady NW, Sallam HF, Elsayed AH, Abdelkader AM, Ali SS, Alanwar A, Abbas AM. The effect of prophylactic oral tranexamic acid plus buccal misoprostol on blood loss after vaginal delivery: a randomized controlled trial. J Matern Fetal Neonatal Med 2017; 32:1806-1812. [PMID: 29241383 DOI: 10.1080/14767058.2017.1418316] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The objective of this study is to evaluate the effect of prophylactic oral tranexamic acid (TA) plus buccal misoprostol on the amount of blood loss after vaginal delivery in women at low risk for post-partum hemorrhage (PPH). MATERIALS AND METHODS The study was a randomized open label clinical trial conducted in a tertiary University Hospital between January 2016 and June 2017. We included women who delivered vaginally with a singleton pregnancy. They were randomized into three groups: group I (women received 10 IU oxytocin IV after delivery of the baby), group II (women received 600 µg buccal misoprostol after delivery of the baby), and group III (women received 1000 mg oral TA at the end of the first stage of labor plus 600 µg buccal misoprostol after delivery of the baby). In each group, pre- and post-delivery pulse rate, blood pressure, temperature, and hemoglobin level were evaluated. Additionally, the amount of blood loss, need for blood transfusion, need for additional uterotonics, and side effects of the study medications were recorded. RESULTS There was a statistically significant lower hemoglobin level and higher blood loss in the misoprostol group compared with oxytocin group and TA plus misoprostol group (p = .0001). There was a statistically significant higher hemoglobin level and lower blood loss in the TA plus misoprostol group compared with the oxytocin group (p = .004 and .043, respectively). PPH occurred in 16.7% of women in the misoprostol group compared 1.7% in the oxytocin group and no cases of PPH in the TA plus misoprostol group (p = .0001). CONCLUSIONS In settings like rural area or home delivery in which oxytocin is not available, alternative oral TA plus buccal misoprostol may be considered as an effective line in prevention of PPH.
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Affiliation(s)
- Nahla W Shady
- a Department of Obstetrics & Gynecology, Faculty of Medicine , Aswan University , Aswan , Egypt
| | - Hany F Sallam
- a Department of Obstetrics & Gynecology, Faculty of Medicine , Aswan University , Aswan , Egypt
| | - Ahmed H Elsayed
- a Department of Obstetrics & Gynecology, Faculty of Medicine , Aswan University , Aswan , Egypt
| | - Abdelrahman M Abdelkader
- b Department of Obstetrics & Gynecology , Faculty of Medicine, Assiut University , Assiut , Egypt
| | - Shymaa S Ali
- b Department of Obstetrics & Gynecology , Faculty of Medicine, Assiut University , Assiut , Egypt
| | - Ahmed Alanwar
- c Department of Obstetrics & Gynecology , Faculty of Medicine, Ain Shams University , Cairo , Egypt
| | - Ahmed M Abbas
- b Department of Obstetrics & Gynecology , Faculty of Medicine, Assiut University , Assiut , Egypt
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Lier H, von Heymann C, Korte W, Schlembach D. Peripartum Haemorrhage: Haemostatic Aspects of the New German PPH Guideline. Transfus Med Hemother 2017; 45:127-135. [PMID: 29765296 DOI: 10.1159/000478106] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 06/07/2017] [Indexed: 12/30/2022] Open
Abstract
Summary Peripartum haemorrhage remains one of the main causes of maternal mortality world-wide. The German, Austrian and Swiss Societies of Gynaecology and Obstetrics have updated the current guidelines for the treatment of peripartum haemorrhage together with the German Society of Anaesthesiology and Intensive Care Medicine and the Society of Thrombosis and Haemostasis Research. The recommendations have been the result of a thorough review of the available scientific literature and a consensus process involving all members of the guideline group. A key element of the anaesthesiological and haemostatic management is the development of a multidisciplinary standard operating procedure combining surgical as well as medical and haemostatic treatments depending on the severity of bleeding. The guideline underscores the value of clinical and laboratory diagnostics of peripartum haemorrhage as early as possible, even pre-emptively. This allows for an early identification of causes of bleeding and a specific treatment. The guideline comprises evidence-based recommendations for the use of uterotonics, tranexamic acid and blood products such as factor concentrates, fresh frozen plasma, platelet concentrates, packed red blood cells, recombinant activated factor VII and desmopressin. In addition, recommendations for blood conservation strategies involving the use of cell salvage, permissive hypotension and transfusion triggers are given.
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Affiliation(s)
- Heiko Lier
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Cologne, Cologne, Germany
| | - Christian von Heymann
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Wolfgang Korte
- Centre for Laboratory Medicine and Haemostasis and Haemophilia Centre, St. Gallen, Switzerland
| | - Dietmar Schlembach
- Department of Obstetrics and Gynaecology, Vivantes Klinikum Neukölln, Berlin, Germany
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Gillissen A, Henriquez DDCA, van den Akker T, Caram-Deelder C, Wind M, Zwart JJ, van Roosmalen J, Eikenboom J, Bloemenkamp KWM, van der Bom JG. The effect of tranexamic acid on blood loss and maternal outcome in the treatment of persistent postpartum hemorrhage: A nationwide retrospective cohort study. PLoS One 2017; 12:e0187555. [PMID: 29107951 PMCID: PMC5673178 DOI: 10.1371/journal.pone.0187555] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 10/21/2017] [Indexed: 01/01/2023] Open
Abstract
Background Recent results show a protective effect of tranexamic acid on death due to bleeding in patients with postpartum hemorrhage in low- and middle-resource countries. We quantify the association between early administration of tranexamic acid compared to late or no administration and severe acute maternal morbidity and blood loss among women suffering from persistent severe postpartum hemorrhage in a high-income country. Methods and findings We performed a nationwide retrospective cohort study in 61 hospitals in the Netherlands. The study population consisted of 1260 women with persistent postpartum hemorrhage who had received at least four units of red cells, or fresh frozen plasma or platelets in addition to red cells. A review of medical records was performed and cross-referenced with blood bank data. The composite endpoint comprised maternal morbidity (hysterectomy, ligation of the uterine arteries, emergency B-Lynch suture, arterial embolization or admission into an intensive care unit) and mortality. Results 247 women received early tranexamic acid treatment. After adjustment for confounding, odds ratio for the composite endpoint for early tranexamic acid (n = 247) versus no/late tranexamic acid (n = 984) was 0.92 (95% confidence interval (CI) 0.66 to 1.27). Propensity matched analysis confirmed the absence of a difference between women with and without tranexamic acid. Blood loss after administration of first line therapy did not differ significantly between the two groups (adjusted difference -177 mL, CI -509.4 to +155.0). Conclusions Our findings suggest that in a high-resource country the effect of tranexamic acid on both blood loss and the combined endpoint of maternal mortality and morbidity may be disappointing.
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Affiliation(s)
- Ada Gillissen
- Centre for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Dacia D. C. A. Henriquez
- Centre for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Thomas van den Akker
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, United Kingdom
| | - Camila Caram-Deelder
- Centre for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands
| | - Merlijn Wind
- Leiden University Medical Center, Leiden, The Netherlands
| | - Joost J. Zwart
- Department of Obstetrics and Gynecology, Deventer Hospital, Deventer, The Netherlands
| | - Jos van Roosmalen
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
- Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands
| | - Jeroen Eikenboom
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Kitty W. M. Bloemenkamp
- Department of Obstetrics, Birth Centre Wilhelmina’s Children Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johanna G. van der Bom
- Centre for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- * E-mail:
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Demos HA, Lin ZX, Barfield WR, Wilson SH, Robertson DC, Pellegrini VD. Process Improvement Project Using Tranexamic Acid Is Cost-Effective in Reducing Blood Loss and Transfusions After Total Hip and Total Knee Arthroplasty. J Arthroplasty 2017; 32:2375-2380. [PMID: 28343823 DOI: 10.1016/j.arth.2017.02.068] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 02/19/2017] [Accepted: 02/22/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Tranexamic acid (TXA) has been associated with decreased blood loss and transfusion after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The purpose of this study was to examine both transfusion utilization and the economic impact of a Process Improvement Project implementing TXA for THA and TKA. METHODS After standardization of TXA administration in THA and TKA patients, retrospective data were compared from 12 consecutive months before (group A, n = 336 procedures) and after (group B, n = 436 procedures) project initiation. RESULTS TXA administration increased with project implementation (group A = 3.57%, group B = 86.01%) and was associated with reductions in perioperative hemoglobin decrement (20.2%), patients transfused (45%), and number of units transfused per patient (61.9%). Cost savings were notable per patient ($128) and annually program wide ($55,884) with the primary THA subgroup contributing the most to the savings. No increase in adverse effects was observed. CONCLUSION Standardized administration of TXA is an effective and economically favorable blood-reduction strategy for patients undergoing elective THA or TKA. Although reduction in transfusions with TXA may be greater after TKA, the economic and clinical impact of transfusion reduction is more substantial in THA patients.
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Affiliation(s)
- Harry A Demos
- Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina
| | - Zilan X Lin
- Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina
| | - William R Barfield
- Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina
| | - Sylvia H Wilson
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Dawn C Robertson
- Department of Enterprise Analytics, Medical University of South Carolina, Charleston, South Carolina
| | - Vincent D Pellegrini
- Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina
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Li C, Gong Y, Dong L, Xie B, Dai Z. Is prophylactic tranexamic acid administration effective and safe for postpartum hemorrhage prevention?: A systematic review and meta-analysis. Medicine (Baltimore) 2017; 96:e5653. [PMID: 28072700 PMCID: PMC5228660 DOI: 10.1097/md.0000000000005653] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND To assess the efficacy and safety of tranexamic acid (TA) in reducing blood loss and lowering transfusion needs for patients undergoing caesarean section (CS) or vaginal delivery (VD). METHODS An electronic literature search of PubMed, EMBASE, OVID, Cochrane library, Scopus, Central, and Clinical trials.gov was performed to identify studies that evaluating the usage of TA in CS or VD. The methodological quality of included trials was assessed and data extraction was performed. RESULTS Finally, 25 articles with 4747 participants were included. Our findings indicated TA resulted in a reduced intra-, postoperative, and total blood loss by a mean volume of 141.25 mL (95% confidence interval [CI] -186.72 to -95.79, P < 0.00001), 36.42 mL (95% CI -46.50 to -26.34, P < 0.00001), and 154.25 mL (95% CI -182.04 to -126.47, P < 0.00001) in CS. TA administration in VD was associated with a reduced intra-, postoperative, and total blood loss by a mean volume of 22.88 mL (95% CI -50.54 to 4.77, P = 0.10), 41.24 mL (95% CI -55.50 to -26.98, P < 0.00001), and 84.79 mL (95% CI -109.93 to -59.65, P < 0.00001). In addition, TA could lower the occurrence rate of postpartum hemorrhage (PPH) and severe PPH, and reduce the risk of blood transfusions. No increased risk of deep vein thrombosis (DVT) after CS or VD was associated with TA usage, while the minor side effects were more common. CONCLUSIONS Our findings indicated that intravenous TA for patients undergoing CS was effective and safe. Although prophylactic TA administration is associated with reduced PPH, current existing data are insufficient to draw definitive recommendations about its clinical significance due to the poor to moderate quality of the included literatures. Thus, high-quality randomized controlled trials with larger samples are needed to validate our findings.
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Affiliation(s)
- Chunbo Li
- Department of Obstetrics and Gynaecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine
| | - Yuping Gong
- Department of Nursing, Zhongshan Hospital of Fudan University
| | - Lingling Dong
- Department of Obstetrics and Gynaecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine
| | - Bingying Xie
- Department of Gynaecology and Obstetrics, Gynaecology and Obstetrics Hospital of Fudan University, Shanghai, China
| | - Zhiyuan Dai
- Department of Obstetrics and Gynaecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine
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Lin ZX, Woolf SK. Safety, Efficacy, and Cost-effectiveness of Tranexamic Acid in Orthopedic Surgery. Orthopedics 2016; 39:119-30. [PMID: 26942474 DOI: 10.3928/01477447-20160301-05] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 08/20/2015] [Indexed: 02/03/2023]
Abstract
Perioperative bleeding and postsurgical hemorrhage are common in invasive surgical procedures, including orthopedic surgery. Tranexamic acid (TXA) is a pharmacologic agent that acts through an antifibrinolytic mechanism to stabilize formed clots and reduce active bleeding. It has been used successfully in orthopedics to reduce perioperative blood loss, particularly in total hip and knee arthroplasty and spine surgery. Numerous research studies have reported favorable safety and efficacy in orthopedic cases, although there is no universal standard on its administration and its use has not yet become the standard of practice. Reported administration methods often depend on the surgeon's preference, with both topical and intravenous routes showing efficacy. The type and anatomic site of the surgery seem to influence the decision making but also result in conflicting opinions. Reported complication rates with TXA use are low. The incidence of both arterial and venous thromboembolic events, particularly deep venous thrombosis and pulmonary embolism, has not been found to be significantly different with TXA use for healthy patients. The route of administration and dosage do not appear to affect complication rates either. However, data on patients with higher-risk conditions are deficient. In addition, TXA has shown potential to reduce blood loss, transfusion rates and volumes, perioperative hemoglobin change, and hospital-related costs at various degrees among the published studies. Conservation of blood products, reduced laboratory costs, and shorter hospital stays are likely the major factors driving the cost savings associated with TXA use. This article reviews current data supporting the safety, efficacy, and cost-effectiveness of TXA in orthopedic surgery.
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Abstract
BACKGROUND Haemoptysis is a common pathology around the world, occurring with more frequency in low-income countries. It has different etiologies, many of which have infectious characteristics. Antifibrinolytic agents are commonly used to manage bleeding from different sources, but their usefulness in pulmonology is unclear. OBJECTIVES To evaluate the effectiveness and safety of antifibrinolytic agents in reducing the volume and duration of haemoptysis in adult and paediatric patients. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE) in The Cochrane Library, EMBASE and LILACS for publications that describe randomized controlled trials (RCTs) of antifibrinolytic therapy in patients presenting with haemoptysis. We also performed an independent search in MEDLINE for relevant trials not yet included in CENTRAL or DARE. Searches are up to date to the 19th September 2016. We conducted electronic and manual searches of relevant national and international journals. We reviewed the reference lists of included studies to locate relevant randomized controlled trials (RCTs). An additional search was carried out to find unpublished RCTs. SELECTION CRITERIA We included RCTs designed to evaluate the effectiveness and safety of antifibrinolytic agents in reducing haemoptysis in adult and paediatric patients of both genders presenting with haemoptysis of any etiology and severity. The intervention of interest was the administration of antifibrinolytic agents compared with placebo or no treatment. DATA COLLECTION AND ANALYSIS All reviewers independently assessed methodological quality and extracted data tables pre-designed for this review. MAIN RESULTS The electronic literature search identified 1 original study that met the eligibility criteria. One unpublished study was also identified through manual searches. Therefore two randomized controlled trials met the inclusion criteria: Tscheikuna 2002 (via electronic searches) and Ruiz 1994 (via manual searches). Tscheikuna 2002, a double-blind RCT performed in Thailand, evaluated the effectiveness of tranexamic acid (TXA, an antifibrinolytic agent) administered orally in 46 hospital in- and outpatients with haemoptysis of various etiologies. Ruiz 1994, a double-blind RCT performed in Peru, evaluated the effectiveness of intravenous TXA in 24 hospitalised patients presenting with haemoptysis secondary to tuberculosis.Pooled together, results demonstrated a significant reduction in bleeding time between patients receiving TXA and patients receiving placebo with a weighted mean difference (WMD) of -19.47 (95% CI -26.90 to -12.03 hours), but with high heterogeneity (I² = 52%). TXA did not affect remission of haemoptysis evaluated at seven days after the start of treatment. Adverse effects caused by the drug's mechanism of action were not reported. There was no significant difference in the incidence of mild side effects between active and placebo groups (OR 3.13, 95% CI 0.80 to 12.24). AUTHORS' CONCLUSIONS There is insufficient evidence to judge whether antifibrinolytics should be used to treat haemoptysis from any cause, though limited evidence suggests they may reduce the duration of bleeding.
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Affiliation(s)
- Gabriela Prutsky
- Mayo ClinicKnowledge and Evaluation Research Unit200 First Street SWRochesterMinnesotaUSAMN 55905
- CONEVID, Unidad de conocimiento y evidencia, Cayetano Heredia Peruvian UniversityLimaPeru
| | - Juan Pablo Domecq
- CONEVID, Unidad de conocimiento y evidencia, Cayetano Heredia Peruvian UniversityLimaPeru
- Henry Ford Health SystemDepartment of Internal MedicineDetroitMichiganUSA48202
| | - Carlos A Salazar
- Universidad Peruana Cayetano HerediaDepartment of MedicineAvenida Honorio Delgado 430San Martin de PorresLimaPeru
| | - Roberto Accinelli
- Departamento de Medicina, Universidad Peruana Cayetano Heredia and Hospital Nacional Cayetano HerediaLaboratorio de Respiración of the Instituto de Investigaciones de la AlturaAv. Honorio Delgado 262 SMPLimaPeru
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Roy P, Sujatha MS, Bhandiwad A, Biswas B. Role of Tranexamic Acid in Reducing Blood Loss in Vaginal Delivery. J Obstet Gynaecol India 2016; 66:246-50. [PMID: 27651612 PMCID: PMC5016452 DOI: 10.1007/s13224-016-0856-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 02/09/2016] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Anti-fibrinolytic agents are used to reduce obstetric blood loss as the fibrinolytic system is known to get activated after placental delivery. OBJECTIVES To evaluate the efficacy of parenteral tranexamic acid in reducing blood loss during normal labour and to compare it with the amount of blood loss in patients who received placebo in the third stage of labour. METHODOLOGY Patients with spontaneous labour or planned for induction of labour and fulfilling the inclusion criteria were recruited for the study. In each patient, the pre-delivery pulse rate, blood pressure, Hb gm% and PCV% were noted. Labour was monitored carefully using a partogram. The study group received Inj. Oxytocin and Inj. Tranexamic acid. The control group received Inj. Oxytocin and Placebo injection. Immediately after delivery of the baby, when all the liquor was drained, the patient was placed over a blood drape-a disposable conical, graduated plastic collection bag. The amount of blood collected in the blood drape was measured. Then the patient was given pre-weighed pads, which were weighed 2 h post-partum. The blood loss was measured by measuring the blood collected in the drape and by weighing the swabs before and after delivery. RESULTS The total number of patients studied was 100-equally distributed in both the groups. The age group of the patients and BMI were comparable. There was a significant increase in the pulse rate and decrease in blood pressure in the control group as compared with the study group. The post-delivery haemoglobin and haematocrit were significantly reduced in the control group as compared to the study group. The mean blood loss at the end of 2 h was 105 ml in the study group and 252 ml in the control group. There was a significant increase in the usage of uterotonics and also in the need for blood transfusion in the control group; 12 % of the patients in the control group had to stay for more than 3 days compared to 2 % in the study group. CONCLUSION Tranexamic acid injection, an antifibrinolytic agent when given prophylactically after the delivery of the baby, by intravenous route appears to reduce the blood loss and maternal morbidity during normal labour effectively.
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Affiliation(s)
- Priyankur Roy
- Department of Obstetrics and Gynaecology, JSS Medical College and Hospital, Mysore, India
| | - M. S. Sujatha
- Department of OBG Unit – II, JSS Medical College and Hospital, JSS University, Mysore, India
| | - Ambarisha Bhandiwad
- Department of OBG, JSS Medical College and Hospital, JSS University, Mysore, India
| | - Bivas Biswas
- Department of Obstetrics and Gynaecology, King’s Mill Hospital, Sutton in Ashfield, Nottinghamshire UK
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Frimat M, Decambron M, Lebas C, Moktefi A, Lemaitre L, Gnemmi V, Sautenet B, Glowacki F, Subtil D, Jourdain M, Rigouzzo A, Brocheriou I, Halimi JM, Rondeau E, Noel C, Provôt F, Hertig A. Renal Cortical Necrosis in Postpartum Hemorrhage: A Case Series. Am J Kidney Dis 2016; 68:50-7. [DOI: 10.1053/j.ajkd.2015.11.022] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 11/29/2015] [Indexed: 11/11/2022]
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Lavee O, Kidson-Gerber G. Update on inherited disorders of haemostasis and pregnancy. Obstet Med 2016; 9:64-72. [PMID: 27512496 PMCID: PMC4950409 DOI: 10.1177/1753495x15624307] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 11/30/2015] [Indexed: 12/18/2022] Open
Abstract
Inherited bleeding disorders have the potential to cause bleeding complications during pregnancy, childbirth and the postpartum period as well as effect fetal outcomes. There is an evolving understanding of the need for specialised and individualised care for affected women during these times. The aim for each patient is to estimate the risk to mother, fetus and neonate; to implement measures to minimise these risks; and to anticipate complications and develop contingencies for these scenarios. This includes accurate diagnosis, preconceptual care, prenatal diagnostic options, antenatal care, delivery and postpartum care as well as care of an affected neonate. An understanding of the physiologic haemostatic changes associated with pregnancy as well as the scope of defects, inheritance and management of inherited bleeding disorders is paramount when caring for these women. Collaborative and prospective management in conjunction with haematology services underpins the approach advocated. This review draws on the available literature, and outlines the principles of care for women with inherited bleeding disorders before, during and after pregnancy, as well as their babies, based on both available data and collective clinical experience.
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Affiliation(s)
- Orly Lavee
- Department of Haematology, South Eastern Sydney Local Health District, Prince of Wales Hospital, New South Wales, Australia
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Maswime S, Buchmann E. Causes and avoidable factors in maternal death due to cesarean-related hemorrhage in South Africa. Int J Gynaecol Obstet 2016; 134:320-3. [PMID: 27352737 DOI: 10.1016/j.ijgo.2016.03.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 02/19/2016] [Accepted: 05/19/2016] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To describe risk factors, clinical events, and avoidable factors in cases of maternal death due to bleeding during and after cesarean delivery. METHODS A retrospective study was undertaken of the clinical records of women who delivered in seven hospitals in Johannesburg, South Africa, between January 2013 and December 2014. Maternal deaths due to cesarean-related hemorrhage during or within 42days of cesarean delivery at 24weeks or more were selected. Case records were audited using quantitative techniques to determine the events leading up to death. RESULTS There were 123 251 deliveries and 17 maternal deaths due to bleeding during or after cesarean (3.2 deaths per 10 000 deliveries). Risk factors included previous cesarean delivery, preoperative anemia, and placental abruption. Uterine atony and surgical trauma were the main causes of bleeding. Five (29%) women died before the cause of bleeding was found. Avoidable factors included delays in the recognition and management of shock. Thirteen (76%) women died within 48hours of the cesarean procedure. CONCLUSION Deaths due to bleeding during and after cesarean have multifactorial causation. Maternal healthcare systems must be strengthened, with attention to the knowledge and skills of health workers. This requires increased clinical vigilance, a rapid effective response to obstetric hemorrhage and shock, and overall health system strengthening.
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Affiliation(s)
- Salome Maswime
- Wits Obstetrics and Gynaecology Clinical Research Division, University of the Witwatersrand, Johannesburg, South Africa.
| | - Eckhart Buchmann
- Wits Obstetrics and Gynaecology Clinical Research Division, University of the Witwatersrand, Johannesburg, South Africa
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Randomized controlled trial of tranexamic acid among parturients at increased risk for postpartum hemorrhage undergoing cesarean delivery. Int J Gynaecol Obstet 2016; 133:312-5. [DOI: 10.1016/j.ijgo.2015.09.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 09/18/2015] [Accepted: 02/02/2016] [Indexed: 11/17/2022]
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A randomized placebo-controlled trial of preoperative tranexamic acid among women undergoing elective cesarean delivery. Int J Gynaecol Obstet 2015; 131:265-8. [DOI: 10.1016/j.ijgo.2015.05.027] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 05/11/2015] [Accepted: 08/05/2015] [Indexed: 11/18/2022]
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Bouet PE, Ruiz V, Legendre G, Gillard P, Descamps P, Sentilhes L. Policy of high-dose tranexamic acid for treating postpartum hemorrhage after vaginal delivery. J Matern Fetal Neonatal Med 2015; 29:1617-22. [PMID: 26118386 DOI: 10.3109/14767058.2015.1056731] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To assess whether a policy of routine administration of high-dose tranexamic acid (TA) at the diagnosis of postpartum hemorrhage (PPH) reduces blood loss after vaginal birth. METHODS This controlled single-center before-and-after study of all women with PPH ≥ 500 ml after vaginal birth took place from January 2011 through March 2012; the control group included those seen from January 2011 through August 2011, and the case patients those from September 2011 through March 2012. Our protocol for the management of PPH was modified effective September 2011 to include administration of high-dose TA (4 g of TA intravenously then 1 g/h for 6 h) once blood loss reached 800 ml. Our primary objective was to assess the efficacy of this policy in reducing blood loss in PPH. RESULTS Maternal characteristics did not differ between the two groups. Mean estimated blood loss was not significantly lower in the TA group (n = 138) than in the control group (n = 151) (respectively, 915.7 ± 321 ml versus 944.8 ± 313.8 ml; p = 0.47). The difference between pre- and post-delivery hemoglobin levels were lower in the TA group (-2.6 g/dl ± 1.2 versus -2.9 g/dl ± 1.3; p = 0.09), but it was not significant. Postpartum iron sucrose injections were significantly less frequent in the TA than the control group (2.2% versus 9.9%; p < 0.05). CONCLUSIONS A policy of high-dose TA in PPH after vaginal deliveries was not associated with a significant reduction of blood loss.
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Affiliation(s)
- Pierre-Emmanuel Bouet
- a Department of Obstetrics and Gynecology , Angers University Hospital , Angers , France
| | - Vanessa Ruiz
- a Department of Obstetrics and Gynecology , Angers University Hospital , Angers , France
| | - Guillaume Legendre
- a Department of Obstetrics and Gynecology , Angers University Hospital , Angers , France
| | - Philippe Gillard
- a Department of Obstetrics and Gynecology , Angers University Hospital , Angers , France
| | - Philippe Descamps
- a Department of Obstetrics and Gynecology , Angers University Hospital , Angers , France
| | - Loïc Sentilhes
- a Department of Obstetrics and Gynecology , Angers University Hospital , Angers , France
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Abstract
BACKGROUND Postpartum haemorrhage (PPH) is a common and potentially life-threatening complication of labour. Several options for preventing PPH are available, but further advances in this field are important, especially the identification of safe, easy to use and cost-effective regimens. Tranexamic acid (TA), which is an antifibrinolytic agent that is used widely to prevent and treat haemorrhage, merits evaluation to assess whether it meets these criteria. OBJECTIVES To determine, from the best available evidence, whether TA is effective and safe for preventing PPH in comparison to placebo or no treatment (with or without uterotonic co-treatment), or to uterotonic agents. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 January 2015) and reference lists of retrieved studies. SELECTION CRITERIA All published, unpublished and ongoing randomised controlled trials (RCTs) evaluating the use of TA alone or in addition to uterotonics in the third stage of labour or during caesarean section (CS) to prevent PPH. DATA COLLECTION AND ANALYSIS Two review authors independently assessed for inclusion all the potential studies identified as a result of the search strategy. We entered the data into Review Manager software and checked for accuracy. MAIN RESULTS Twelve trials involving 3285 healthy women at low risk of excessive bleeding undergoing elective CS (nine trials, 2453 participants) or spontaneous birth (three trials, 832 participants) satisfied inclusion criteria and contributed data to the analysis. All participants received routine prophylactic uterotonics in accordance with the local guideline in addition to TA or placebo or no intervention. Overall, included studies had moderate risk of bias for random sequence generation, allocation concealment, blinding, selective reporting and low risk of bias for incomplete data. The quality of evidence was also as assessed using GRADE.Blood loss greater than 400 mL or 500 mL, and more than 1000 mL was less common in women who received TA versus placebo or no intervention (risk ratio (RR) 0.52, 95% confidence interval (CI) 0.42 to 0.63, six trials, 1398 women; moderate quality evidence) and (RR 0.40, 95% CI 0.23 to 0.71, six trials, 2093 women; moderate quality evidence), respectively. TA was effective in decreasing the incidence of blood loss greater than 1000 mL in women who had undergone CS (RR 0.43, 95% CI 0.23, 0.78, four trials, 1534 women), but not vaginal birth (RR 0.28, 95% CI 0.06, 1.36, two trials 559 women). The effect of TA on blood loss greater than 500 mL or 400 mL was more pronounced in the group of women having vaginal birth than in women who had CS. Mean blood loss (from delivery until two hours postpartum) was lower in women who received TA versus placebo or no intervention (mean difference MD - 77.79 mL, 95% CI -97.95, -57.64, five trials, 1186 women) and this effect was similar following vaginal birth and CS.Additional medical interventions (moderate quality evidence) and blood transfusions were less frequent in women receiving TA versus placebo or no interventions. Mild side effects such as nausea, vomiting, dizziness were more common with the use of TA (moderate quality evidence). The effect of TA on maternal mortality, severe morbidity and thromboembolic events is uncertain (low quality evidence). AUTHORS' CONCLUSIONS TA (in addition to uterotonic medications) decreases postpartum blood loss and prevents PPH and blood transfusions following vaginal birth and CS in women at low risk of PPH based on studies of mixed quality. There is insufficient evidence to draw conclusions about serious side effects, but there is an increase in the incidence of minor side effects with the use of TA. Effects of TA on thromboembolic events and mortality as well as its use in high-risk women should be investigated further.
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Affiliation(s)
- Natalia Novikova
- Department of Obstetrics and Gynaecology, East London Hospital Complex, Walter Sisulu University, Private Bag X9047, East London, South Africa, 5200
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Sentilhes L, Daniel V, Darsonval A, Deruelle P, Vardon D, Perrotin F, Le Ray C, Senat MV, Winer N, Maillard F, Deneux-Tharaux C. Study protocol. TRAAP - TRAnexamic Acid for Preventing postpartum hemorrhage after vaginal delivery: a multicenter randomized, double-blind, placebo-controlled trial. BMC Pregnancy Childbirth 2015; 15:135. [PMID: 26071040 PMCID: PMC4465316 DOI: 10.1186/s12884-015-0573-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 05/28/2015] [Indexed: 01/31/2023] Open
Abstract
Background Postpartum hemorrhage (PPH) is a major cause of maternal mortality, accounting for one quarter of all maternal deaths worldwide. Estimates of its incidence in the literature vary widely, from 3 % to 15 % of deliveries. Uterotonics after birth are the only intervention that has been shown to be effective in preventing PPH. Tranexamic acid (TXA), an antifibrinolytic agent, has been investigated as a potentially useful complement to uterotonics for prevention because it has been proved to reduce blood loss in elective surgery, bleeding in trauma patients, and menstrual blood loss. Randomized controlled trials for PPH prevention after cesarean (n = 10) and vaginal (n = 2) deliveries show that women who received TXA had significantly less postpartum blood loss without any increase in their rate of severe adverse effects. However, the quality of these trials was poor and they were not designed to test the effect of TXA on the reduction of PPH incidence. Large, adequately powered, multicenter randomized controlled trials are required before the widespread use of TXA to prevent PPH can be recommended. Methods and design A multicenter, double-blind, randomized controlled trial will be performed. It will involve 4000 women in labor for a planned vaginal singleton delivery, at a term ≥ 35 weeks. Treatment (either TXA 1 g or placebo) will be administered intravenously just after birth. Prophylactic oxytocin will be administered to all women. The primary outcome will be the incidence of PPH, defined by blood loss ≥500 mL, measured with a graduated collector bag. This study will have 80 % power to show a 30 % reduction in the incidence of PPH, from 10.0 % to 7.0 %. Discussion In addition to prophylactic uterotonic administration, a complementary component of the management of third stage of labor acting on the coagulation process may be useful in preventing PPH. TXA is a promising candidate drug, inexpensive, easy to administer, and simple to add to the routine management of deliveries in hospitals. This large, adequately powered, multicenter, randomized placebo-controlled trial seeks to determine if the risk-benefit ratio favors the routine use of TXA after delivery to prevent PPH. Trial registration ClinicalTrials.gov NCT02302456 (November 17, 2014)
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Affiliation(s)
- Loïc Sentilhes
- Department of Obstetrics and Gynecology, Angers University Hospital, 4, rue Larrey, 49933, Angers, France.
| | - Valérie Daniel
- Department of Pharmacy, Angers University Hospital, Angers, France. .,PPRIGO (Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest) Brest University Hospital, Brest, France.
| | - Astrid Darsonval
- Department of Pharmacy, Angers University Hospital, Angers, France. .,PPRIGO (Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest) Brest University Hospital, Brest, France.
| | - Philippe Deruelle
- Department of Obstetrics and Gynecology, Jeanne de Flandre University Hospital, Lille, France.
| | - Delphine Vardon
- Department of Obstetrics and Gynecology, Caen University Hospital, Caen, France.
| | - Franck Perrotin
- Department of Obstetrics and Gynecology, Tours University Hospital, Tours, France.
| | - Camille Le Ray
- Port-Royal Maternity Unit, Department of Obstetrics and Gynecology, Cochin University Hospital, APHP, Paris, France. .,INSERM, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Biostatistics (U1153), Risks in pregnancy DHU, Paris-Descartes University, Paris, France.
| | - Marie-Victoire Senat
- Department of Obstetrics and Gynecology, Kremlin-Bicetre University Hospital, APHP, Paris, France.
| | - Norbert Winer
- Department of Obstetrics and Gynecology, Nantes University Hospital, Nantes, France.
| | - Françoise Maillard
- INSERM, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Biostatistics (U1153), Risks in pregnancy DHU, Paris-Descartes University, Paris, France.
| | - Catherine Deneux-Tharaux
- INSERM, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Biostatistics (U1153), Risks in pregnancy DHU, Paris-Descartes University, Paris, France.
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Economou M, Banov L, Ljung R. Perinatal aspects of haemophilia. Eur J Haematol 2015; 76:21-5. [PMID: 24957104 DOI: 10.1111/ejh.12371] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2014] [Indexed: 11/29/2022]
Abstract
Haemophilia is an X-linked recessive genetic disease of haemostasis. Women carriers may present with a bleeding tendency similar to milder forms of the disease. Haemophilic newborns present risk factors and patterns of bleeding that are challenging. Identification of carriers and genetic counselling before conception is considered optimal to help decide on available conception options and during pregnancy to help minimise bleeding risks for both carrier mother and affected baby. Preimplantation genetic diagnosis is attractive to many couples at risk of having a child with haemophilia and relevant technology is becoming more available although it has both practical and ethical limitations. Pregnancy in carriers should be managed by a multidisciplinary team in a comprehensive treatment centre. The optimal mode of delivery for carriers expecting a baby known to have or being at risk of haemophilia is an issue of great debate. The general consensus among authors is avoidance of instrumental delivery, foetal scalp electrodes and blood sampling in pregnancies at risk of carrying an affected foetus, as well as early recourse to Caesarean section as guided by obstetric indications. Intracranial haemorrhage, although infrequent, is one the most devastating types of bleeding in haemophilic newborns and can occur regardless of the mode of delivery or the severity of haemophilia. Early screening is proposed for all infants with severe or moderate haemophilia who have had traumatic delivery and/or have evidence of extracranial haemorrhage. Women with postpartum haemorrhage should have a bleeding work-up.
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Affiliation(s)
- Marina Economou
- 1st Pediatric Department, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Sentilhes L, Lasocki S, Ducloy-Bouthors A, Deruelle P, Dreyfus M, Perrotin F, Goffinet F, Deneux-Tharaux C. Tranexamic acid for the prevention and treatment of postpartum haemorrhage. Br J Anaesth 2015; 114:576-87. [DOI: 10.1093/bja/aeu448] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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Uterine balloon tamponade in combination with topical administration of tranexamic Acid for management of postpartum hemorrhage. Case Rep Obstet Gynecol 2015; 2015:195036. [PMID: 25861495 PMCID: PMC4377388 DOI: 10.1155/2015/195036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 03/02/2015] [Accepted: 03/05/2015] [Indexed: 11/17/2022] Open
Abstract
While uterine balloon tamponade is an effective modality for control of postpartum hemorrhage, the reported success rates have ranged from the level of 60% to the level of 80%. In unsuccessful cases, more invasive interventions are needed, including hysterectomy as a last resort. We developed a modified tamponade method and applied it to two cases of refractory postpartum hemorrhage after vaginal delivery. The first case was accompanied by uterine myoma and low-lying placenta. After an induced delivery, the patient had excessive hemorrhage due to uterine atony. Despite oxytocin infusion and bimanual uterine compression, the total blood loss was estimated at 2,800 mL or more. The second case was diagnosed as placental abruption complicated by fetal death and severe disseminated intravascular coagulation, subsequently. A profuse hemorrhage continued despite administration of uterotonics, fluid, and blood transfusion. The total blood loss was more than 5,000 mL. In each case, an intrauterine balloon catheter was wrapped in gauze impregnated with tranexamic acid, inserted into the uterus, and inflated sufficiently with sterile water. In this way, mechanical compression by a balloon and a topical antifibrinolytic agent were combined together. This method brought complete hemostasis and no further treatments were needed. Both the women left hospital in stable condition.
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