Among women with vaginal delivery who received prophylactic oxytocin, the use of tranexamic acid did not result in a rate of postpartum hemorrhage of at least 500 ml that was significantly lower than the rate with placebo. (Funded by the French Ministry of Health; TRAAP ClinicalTrials.gov number, NCT02302456 .).
Objective To assess the impact of controlled cord traction on the incidence of postpartum haemorrhage and other characteristics of the third stage of labour in a high resource setting.Design Randomised controlled trial. Setting Five university hospital maternity units in France.Participants Women aged 18 or more with a singleton fetus at 35 or more weeks' gestation and planned vaginal delivery.Interventions Women were randomly assigned to management of the third stage of labour by controlled cord traction or standard placenta expulsion (awaiting spontaneous placental separation before facilitating expulsion). Women in both arms received prophylactic oxytocin just after birth.Main outcome measure Incidence of postpartum haemorrhage ≥500 mL as measured in a collector bag. ResultsThe incidence of postpartum haemorrhage did not differ between the controlled cord traction arm (9.8%, 196/2005) and standard placenta expulsion arm (10.3%, 206/2008): relative risk 0.95 (95% confidence interval 0.79 to 1.15). The need for manual removal of the placenta was significantly less frequent in the controlled cord traction arm (4.2%, 85/2033) compared with the standard placenta expulsion arm (6.1%, 123/2024): relative risk 0.69, 0.53 to 0.90); as was third stage of labour of more than 15 minutes (4.5%, 91/2030 and 14.3%, 289/2020, respectively): relative risk 0.31, 0.25 to 0.39. Women in the controlled cord traction arm reported a significantly lower intensity of pain and discomfort during the third stage than those in the standard placenta expulsion arm. No uterine inversion occurred in either arm. ConclusionsIn a high resource setting, the use of controlled cord traction for the management of placenta expulsion had no significant effect on the incidence of postpartum haemorrhage and other markers of postpartum blood loss. Evidence to recommend routine controlled cord traction for the management of placenta expulsion to prevent postpartum haemorrhage is therefore lacking.Trial registration ClinicalTrials.gov NCT01044082. IntroductionPostpartum haemorrhage remains a major complication of childbirth worldwide.1 Population based studies in high resource countries report a prevalence of severe postpartum haemorrhage of 0.5% to 1% of deliveries, 2-5 making it the main component of severe maternal morbidity. Uterine atony is the leading cause of postpartum haemorrhage, accounting for 60-80% of cases. 6Prevention of atonic postpartum haemorrhage is thus crucial, Active management of the third stage of labour has been proposed for the prevention of postpartum haemorrhage. 7 The standard definition for active management combines three procedures: an oxytocic drug administered immediately after birth, early cord clamping and cutting, and controlled cord traction. Several trials [8][9][10][11] in a meta-analysis 12 showed that active management of the third stage of labour is associated with a 60% reduction in the incidence of postpartum haemorrhage compared with expectant management. Given its efficacy, active management of the t...
BackgroundPostpartum 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 designA 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 %.DiscussionIn 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 registrationClinicalTrials.gov NCT02302456 (November 17, 2014)
We measured the clinical tibiofemoral (TF) angle and the intercondylar (IC) or intermalleolar (IM) distance in 427 normal European children (212 male and 215 female) aged from 10 to 16 years. In our study, girls had a constant valgus (5.5#{176}) and displayed an IM distance of <8 cm or an IC distance of <4 cm. By contrast, boys had a varus evolution (4.4#{176}) during the last two years of growth and displayed an IM distance of <4 cm or an IC distance of <5 cm. Values above these for genu varum or genu valgum may require careful follow-up and evaluation. J Bone Joint Surg [Br] 1995:77-B:729-32.
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