Role of Prophylactic Tranexamic Acid in Reducing Blood Loss during Elective Caesarean Section: A Randomized Controlled Stud y

Abstract

INTRODUCTIONEvery year over five lac women die worldwide due to causes related to pregnancy and delivery. Postpartum Haemorrhage (PPH) accounts for the major part of the mortality as well as morbidity like severe anaemia, need for blood transfusion, hospital stay and infection. Millennium Development Goal 5 targets for reduction of maternal mortality rate by 75% by 2015, which means 5.5% reduction per year is required. People at high risk of PPH account for only small percent of all maternal deaths. Majority of morbidity and mortality happen in those with no risk factors and cannot be predicted. In an analysis of 1620 women in rural India, it was found that 9.2% experienced PPH. No maternal or socio-demographic factors differed between women with PPH and those without [1]. Though the incidence of early PPH (occurring within 24 hours of delivery) is lower in caesarean section than vaginal delivery, the former is a major surgery and causes greater blood loss. Hence, it is essential to prevent the blood loss effectively in a feasible way, thus, explaining the need for this study.Apart from obstetric, surgical and radiological interventions, pharmacologic management also plays an important role in this aspect. Uterine atony is the most common cause for PPH. First line of therapeutic management for PPH is oxytocin [2] Other modalities include intravenous ergometrine, intra-muscular carboprost and misoprostol. Prohaemostatic drugs such as TXA provide a complementary biochemical haemostatic effect to the well proven uterotonics, especially oxytocin. Systemic anti-fibrinolytic agents are widely used in surgery. A systematic review of randomised controlled trials of anti-fibrinolytic agents in elective surgical patients identified 211 randomised controlled trials [3]. The results showed that aprotinin reduced the risk of blood transfusion by 34% and TXA by 39%. TXA is an analogue of lysine that inhibits fibrinolysis by competitively binding to plasminogen. It prevents the lysis of formed clot by inhibiting activation of plasminogen and plasmin. It is ten times more potent than Amino-caproic acid [4,5]. TXA has been shown to reduce uterine blood loss in non-surgical aspect. A study done on women with menorrhagia has showed significant reduction in mean menstrual blood loss in those treated with TXA [6]. A randomized controlled trial assessed TXA for the treatment of PPH and it showed that a high dose of TXA reduces blood loss in women with PPH [7]. Several RCTs have analysed the prophylactic role of TXA (described in discussion) and have shown significant results in reducing blood loss [8][9][10][11][12][13][14][15][16]. TXA might reduce the need for hysterectomy, reduce the risk of severe anaemia and avoid the need for blood transfusion; hence, this could contribute significantly to the goal of reducing maternal mortality. MATERIALS AND METHODS ABSTRACTIntroduction: Obstetric haemorrhage accounts for 20-25% of maternal mortality and morbidity. Anti-fibrinolytics are being widely used in field of surgery. It is also used...

FIGO consensus guidelines on placenta accreta spectrum disorders: Nonconservative surgical management,

“…A recent meta‐analysis of nine trials involving 2365 patients confirmed these findings, demonstrating that the administration of tranexamic acid before cesarean delivery significantly reduces intra‐ and postoperative blood loss and blood transfusion with no increase in thromboembolic events . After this analysis, three more placebo‐controlled trials have shown that tranexamic acid administration immediately before cesarean delivery significantly reduces reported intraoperative blood loss and postoperative declines in hemoglobin without any increase in adverse maternal or neonatal effects …”

“…48 After this analysis, three more placebocontrolled trials have shown that tranexamic acid administration immediately before cesarean delivery significantly reduces reported intraoperative blood loss and postoperative declines in hemoglobin without any increase in adverse maternal or neonatal effects. [49][50][51] No trials have specifically examined the role of tranexamic acid in the surgical management of PAS disorders. However, the quality of the evidence on postpartum hemorrhage justifies its use in the management of women diagnosed prenatally or presenting with PAS disorders at the time of delivery.…”

Role of intravenous tranexamic acid in reducing blood loss during caesarean section: Study at tribal‐dominated area hospital in Chhattisgarh, India

“…It is a known fact that there is release of coagulant factors as well as rapid degradation of fibrinogen and fibrin during placental delivery owing to vascular injury. 20 These physiological events increase fibrinolysis which can last for several hours postpartum. What complicates the matter in CS delivery is the fact that extensive tissue injury caused by the operative procedure contributes further to this process of increased fibrinolysis and resultant bleeding.…”

“…This observation is in accordance with others where only 3.33% women of study arm had this much amount of blood loss in comparison to 60% of the control group (which was 18% in the present study). 20 Cochrane review published promising results for decreased mean blood loss of greater than 500 mL to be more apparent with vaginal births whereas blood loss greater than 1000 mL was decreased with the use of TXA in caesarean section. 7 Moreover in a meta analysis, the mean total blood loss during and after CS was significantly less in TXA group than in control group having a mean difference of 141.61 mL with 95% confidence interval (CI) of 207.09 − 76.14 (P < 0.01).…”

“…6 TXA has also been studied extensively to reduce blood loss in and after CS. [7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] Intravenous TXA is a synthetic derivative of the amino acid lysine that exerts its antifibrinolytic effect through the reversible blockade of lysine binding site on plasminogen molecules. Adverse drug reaction of TXA are nausea, headache, and thromosis.…”