Sowmya, B (2012) Role of tranexamic acid in reducing blood loss in normal labour. Masters thesis, K.A.P. Viswanathan Government Medical College, Tiruchirappalli.
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Abstract
INTRODUCTION: Gods interest in the human race is nowhere better evinced than in obstetrics – Martin H. Fischer. Child birth is one of the most marvelous and memorable segment in a woman’s life. The art of vaginal birth is a unique experience and calls for a celebration. Although the incidence of caesarean section is increasing throughout the world, the art of vaginal birth has not lost its charm. Birth is a life changing event. The care given to woman during labour has the potential to affect her both physically and emotionally in the short and long term. Though labour is a physiological process, it is often associated with morbidity and mortality. The most common cause being blood loss. Life threatening obstetric hemorrhage occurs in approximately 1 per 1000 deliveries. The most recent Practice Bulletin from the American College of Obstetrics and Gynaecology places the estimate at 1,40,000 maternal deaths per year or 1 woman every 4 minutes. There are a number of drugs available for the management of PPH. The recent ones being the anti fibrinolytics and recombinant factor VII. Postpartum haemorrhage (PPH) remains a leading cause of maternal mortality, especially in developing countries (Ronsmons 2006). In confidential enquiries into maternal deaths in South Africa (2005 to 2007) (Confidential enquiries 2006), 383 maternal deaths due to PPH were reported and the majority of these were considered to be preventable. Of these deaths, 67 (17.5%) were caused by uterine atony, where uterotonics were required to control the bleeding. Other cases of maternal death from PPH were due to uterine rupture (37 in women with previous caesarean sections and 43 in women without previous caesarean sections), retained placenta (88), inverted uterus (seven), and other genital tract trauma including caesarean section (141). The great majority were thus not due to uterine atony, and attempts to address the problem need to go beyond the use of uterotonic drugs. Because of the difficulty of randomised trials in women presenting with PPH, the use of tranexamic acid for preventing PPH in high-risk women could be regarded as a proxy for assessing its use for treating PPH. In particular, high-risk factors which may not be responsive to uterotonics, such as placenta praevia and lacerations from instrumental delivery, may respond to tranexamic acid. If tranexamic acid is found to be effective in the prevention of PPH in such highrisk women, its use could be extrapolated to the treatment of PPH (as has been the case for most treatments for PPH, such as oxytocin and ergometrine). The changes in the fibrinolytic components during and immediately after placental delivery are consistent with fibrinolysis occurring as a response to local fibrin deposition. The plasma fibrinogen level decreases during the 3rd stage of labour and after placental delivery, and the level of fibrin/ fibrinogen degradation products in the serum increases 1 hour after child birth and remains raised in the early puerperium. Hence antifibrinolytics will be effective in reducing blood loss by interacting with the fibrinolytic mechanism. AIM OF THE STUDY: 1. To evaluate the efficacy of parenteral Tranexamic Acid in reducing blood loss during normal labour. 2. To compare it with the amount of blood loss in patients who did not receive Tranexamic Acid in the 3rd stage. MATERIALS AND METHODS: The subjects of this prospective randomised placebo controlled study were 200 pregnant women who were admitted in the labour ward of Annal Gandhi Memorial Government Hospital – Trichy, in the time period from July 2010 to July 2011. In all patients detailed history – medical history, obstetric history were taken. Vital parameters checked and basic investigations done. Weight of the patient checked. Detailed general examination and obstetric examination done. Gestational age confirmed by USG. 100 patients were placed in study group and 100 patients were placed in control group. All patients were counselled and informed consent obtained. Study group received: 1. Oxytocin 10 units im within 1 minute of delivery. 2. Inj. Tranexamic acid 10 mg / kg slow direct iv over 5 minutes period at delivery of anterior shoulder. Control group received: 1. Oxytocin 10 units im within 1 minute of delivery. 2. Placebo injection of normal saline 5 ml slow direct iv over 5 minutes period at delivery of anterior shoulder. Inclusion Criteria: 1. Primi and 2nd gravida, 2. More than 38 weeks of gestation, 3. spontaneous / induced labour. Exclusion Criteria: Women with risk factors for PPH were not included in this study. 1. Haemoglobin < 8gm%, 2. Twin pregnancy, 3. Polyhydramnios, 4. EFW > 4 kg, 5. Previous H/O PPH, 6. Fibroid complicating pregnancy, 7. Preeclampsia, 8. Placenta previa, 9. Abruptio placenta, 10. Prolonged and obstructed labour, 11. Heart disease complicating pregnancy, 12. Renal / liver disease patients, 13. Patients on anticoagulants., 14. Previous H/O thromboembolism, 15. Gravidity ≥ 3. Methods: Study group and Control group patients received the injections as above mentioned. In each case the following parameters were noted. 1. Predelivery PR, BP, RR, SpO2, urine output in ml / hr, Hb gm%, PCV% was noted. 2. Blood loss from delivery of the baby to 2hrs post partum was noted. 3. The Apgar scores was noted. 4. Side effects of the drug was noted. 5. Post partum PR, BP, RR, SpO2, urine output in ml / hr, Hb gm%, PCV% was noted. 6. Maternal needs for blood transfusion was noted. 7. Maternal outcome till discharge was noted. RESULTS; 200 patients were selected for the study, 100 as study group and 100 as Control group. • 50% of the cases belonged to the age group 20 – 24 years. • 74% of the cases belonged to class V socioeconomic status. • 25% of the cases were primigravida and 75% of the cases were 2nd gravida. • 82% of the cases were booked cases. • There was no statistically significant difference in the subjective characters in between the two groups. • There was statistically significant fall in blood pressure and rise in PR without any significant change in RR in the control group compare to the study group. • Hb level and hematocrit was significantly reduced in the control group compared to the study group. • Tranexamic acid significantly reduced the blood loss from the time of delivery to 2 hour post partum. • The need for additional uterotonics and maternal blood transfusion is significantly reduced in the study group compared to the control group. • The incidence of vomiting, shivering, fever were statistically insignificant. • None of the patients in both the groups had thromboembolic complications postnatally. • The apgar scores and neonatal outcome was similar in both the groups. • The duration of stay was found to be reduced in the study group when compared to the control group. CONCLUSION: Tranexamic acid injection, an antifibrinolytic agent when given prophylactically at the delivery of the anterior shoulder, by intravenous route appears to reduce the blood loss during normal labour effectively. Some studies demonstrated that tranexamic acid minimally increases the risk of thromboembolism but without statistical significance which was not observed in our study. So, further studies are also needed to support its efficacy.
| Item Type: | Thesis (Masters) |
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| Uncontrolled Keywords: | tranexamic acid ; reducing blood loss ; normal labour. |
| Subjects: | MEDICAL > Obstetrics and Gynaecology |
| Depositing User: | Subramani R |
| Date Deposited: | 24 Nov 2017 17:53 |
| Last Modified: | 24 Nov 2017 17:53 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/4006 |
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