Role of Prophylactic Tranexamic Acid in Reducing Blood Loss during Elective Cesarean Delivery

Research Article

J Fam Med. 2020; 7(8): 1227.

Role of Prophylactic Tranexamic Acid in Reducing Blood Loss during Elective Cesarean Delivery

Albaz Z*

Department of Obstetrics and Gynecology, Alexandria University, Egypt

*Corresponding author: Zeinab Albaz, El-shatby Maternity University Hospital, Faculty of Medicine, Alexandria University, Alexandria, Egypt

Received: July 19, 2020; Accepted: November 13, 2020; Published: November 20, 2020


Each year, worldwide, about 530,000 women die from causes related to pregnancy and childbirth. Nearly all (99%) of these deaths are in low and middle income countries [1]. Although maternal mortality has become a rare event in developed countries, it nonetheless remains a crucial indicator of the quality of obstetric care and the health status of mothers. Haemorrhage, which usually occurs in the postpartum period, is responsible for between one quarter and one third of obstetric deaths worldwide [2]. About one in five of these haemorrhages progresses to a severe form that may endanger the mother's life or at least her future fertility Also PPH causes maternal morbidity as blood transfusion (which can transmit blood borne viral infections, adverse reactions), severe anaemia and postpartum pituitary infarction [3]. Primary Postpartum Haemorrhage (PPH) is considered if blood loss within the first 24 hours after delivery (vaginal or cesarean) ≥1000 ml or associated with manifestations of hypovolemia inspite of amount of blood loss [4]. Traditional definitions depended on mode of delivery, if estimated blood loss ≥500 ml with vaginal delivery and ≥1000 ml with cesarean delivery were considered primary postpartum haemorrhage [5]. Prevalence estimates for PPH in the literature vary widely, from 3% to 15% of deliveries [6-8]. This diversity is explained partly by the variety of criteria and methods used to define PPH: definitions are based on haematological indicators or on the volume of blood loss, which in turn can be estimated clinically or measured more objectively by, for example, a blood collection bag. 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.

The most common causes of postpartum haemorrhage are uterine atony, abnormal placentation including placental abruption, lower genital tract lacerations, retained placental tissue, coagulopathies, vessel malformation, and uterine rupture [9]. Risk factors for atonic PPH include primiparity, macrosomia, multiple pregnancy, previous PPH, obesity, prolonged or augmented labor, polyhydraminos, previous cesearean delivery, antepartum haemorrhage, morbid adherent placenta, anaemia, blood disease, coagulation defect, pregnancy induced hypertension, fibromyomata and elective cesarean section [10]. Nevertheless, most women with PPH have low-risk pegnancies and no identifiable risk factors.

During delivery, when the placenta separates from the uterine wall, sequential physiologic and hemostatic changes occur and reduce bleeding, including strong myometrial contractions, increased platelet activity, and massive release of coagulant factors; at the same time, however, fibrinolytic actvity increases [12]. The placental separation is a critical window for the prevention of PPH so; they can be schematically divided into two categories: those involving a mechanical mechanism and those involving prohaemostatic agents. Active Management of the Third Stage of Labour (AMTSL), consisted of a combination of the following interventions: administration of uterotonic agents immediately after delivery of the child, early cord clamping and cutting, Controlled Cord Traction (CCT), and uterine massage [13,14]. It has been shown that the administration of uterotonics, and in particular oxytocin, after birth is the only component of AMTSL that is effective in preventing PPH. However, in addition to this enhancement of mechanical haemostasis, a complementary biochemical haemostatic effect might be expected from the use of prohaemostatic drug such as TXA [13,14].

Tranexamic Acid (TXA) is an amino acid lysine synthetic derivative, it is a potent antifibrinolytic agent that exerts its effect by blocking lysine binding sites on plasminogen molecules and has the potential to enhance the effectivness of the patient s own hemostatic mechanisms, so clot breakdown (fibrinolysis) is inhibited and bleeding is reduced [15]. The administration of TXA in planned surgery reduces the risk of blood transfusion, mean transfused volume, and need for re-operation due to bleeding, without increasing thrombotic events [16]. Significant reductions of 26-54 % vs placebo orcontrol in mean menstrual blood loss were reported in women with menorrhagia treated with TXA [17]. This result is particularly significant since the efficacy of TXA in menorrhagia suggests that it can reduce uterine blood loss, even of low volume, and in a nonsurgical context. This provides further support for the hypothesis that TXA might be effective for the prevention of PPH after both caesarean and vaginal deliveries. Therefore, during labour the administration of oxytocin enhances the myometrial contraction, and TXA might be able to counter the increased fibrinolytic activity and thus facilitate the hemostatic process.

There is a risk of venous thromboembolism during pregnancy and especially during the puerperium, There is no significant increase in the incidence of thrombotic events related to TXA has been observed in any trial of TXA among pregnant women(n=2228), including RCTs, observational nonrandomized studies and case series [18].

The aim of this study was to assess the efficacy of slowly intravenous administration of antifibrinolytic agent (TXA) on reducing blood loss during elective Cesarean delivery.

Patients and Methods

The study was conducted on 200 women who were admitted at Shatby Maternity University Hospital during the period from January 2019 till November 2019, who were planned to be delivered by elective LSCS. It was Prospective double randomized open(not blind) study. The individual information on the study wasa given for the women in late pregnancy during prenatal visits and was repeated again during labour, good counselling of each women and then confirmation of her participation and informed written consent before delivery.

Inclusion criteria

Age of patients between 19 and 38 yrs, primiparous/multiparous, singleton full term (gestational age of 37 to 42 wks) pregnancy. They were divided into 2 groups, as control and study groups each one comprised of 100 patients.

Exclusion criteria

History of thromboembolic disorders, any medical disorders( renal, liver, brain or cardivascular diseases), severe hemorrhagic disease, Eclampsia, HELLP syndrome, anemia, anticoagulant therapy, allergy to TXA, IUFD, macrosomic baby, multiple pregnancy, polyhydraminos, preterm labour, antepartum hemorrhage, morbid adherent placenta.

Full detailed history was taken to exclude the women had exclusion criteria, general physical and obstetric examination and all routine investigations needed for operation as hemoglobin level, haematocrit value, liver, kidney function and coagulation profile, also obstetric ultrasound. Women were classified randomly into two groups using a computer-generated randomization system, to receive either 1 g of TXA or placebo (normal saline). TXA injection was prepared by diluting 1 gram (10ml) TXA in 100ml of normal saline. TXA was administered as intravenous infusion (over 15 minutes), at least 20 minutes prior to skin incision, to those in study group while normal saline was given to the control group. Spinal anaesthesia was done for all participants. After delivery of the neonate, routine care was given to both groups i.e. 10 units of oxytocin was added to ringer lactate and allowed to flow at rate of 75 to 100ml/hour for 3 hours after surgery. No subjects were eliminated from study.