الفهرس 
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Abstract
Postpartum haemorrhage (PPH) is the leading cause of maternal death worldwide. All deaths occur soon after giving birth and almost all occur in low-income and middle-income countries. PPH was defined as blood loss ≥ 500 ml and ≥ 1000 ml, in normal labour and cesarean section respectively.
Treatment of post partum hemorrhage may include drugs to increase uterine contractility like oxytocin, ergot alkaloids, carboprost and prostaglandins. Also surgical procedures including uterine compression, sutures, arterial ligation, selective artery embolization, intrauterine tamponade and hysterectomy, may be used.
Tranexamix acid (TXA) is an old drug which was discovered in 1950 by Utako Okamoto with her husband Shosuke Okamoto. It is a synthetic derivative of the amino acid lysine that blocks the lysine binding sites of plasminogen and plasmin, inhibiting their effects, including their fibrinolytic and inflammatory effects. TXA showed success in controlling bleeding in many fields like cardiac surgeries, orthopedic surgeries and trauma. Recently it is used also in obstetric field.
The aim of this work was to evaluate the effectiveness and safety of tranexamic acid in reducing the incidence of post-partum hemorrhage after elective cesarean section under spinal anaesthesia through assessment of intraoperative bleeding and detection of side effects e.g.: nausea, vomiting, dizziness, thromboembolic complications, etc.
The present double blind study was carried out in El-Shatby University Hospital on 100 pregnant females aged between 19 to 34 years, gestational age of 37 to 42 weeks and American Society of Anaesthesia (ASA) I or II who was scheduled for elective cesarean section under spinal anaesthesia. Patients were excluded upon patient refusal, allergy to tranexamic acid, history of thromboembolic disorders, height: less than 150 centimeters (cm) or more than 180 cm, weight: BMI more than 30 kilograms per square meter (kg/m2), tendency for increased bleeding like abnormal placentation, multiple pregnancy, polyhydramnios, previous two or more caesarean sections, prior blood transfusion due to anaemia as well as medical problems like chronic hypertension and pre-eclampsia, renal disease or heart disease.
Patients was divided into two equal groups (50 patients each) in a randomized manner.
group 1: Patients received tranexamic acid loading dose of 1 gram (g), 100 milligrams per milliliter (mg/ml) intravenous (IV) at 1 mL per minute (ml/m) (i.e., administered over 10 minutes), 20 minutes before induction of spinal anaesthesia.
group 2: patients received placebo.
Evaluation of the patients was carried out through detailed medical and surgical history talking, full clinical examination and all needed laboratory investigations. Preoperative fasting for 8 hours.
Before the administration of spinal anaesthesia, a 20 gauge intravenous cannula was sited in the non-dominant hand and a preload of 15 ml/kg lactated ringer’s solution was given within 15 minutes. Tranexamic acid was administered by a syringe pump as a loading dose of 1g (100 mg/ml) at infusion rate of 1 ml/min over 10 minutes, 20 minutes before induction of spinal anaesthesia.
Spinal anaesthesia was administered with the patient in the setting position. After skin infiltration with lidocaine, a 25 G Quincke spinal needle was inserted at L3-4 interspace and 10-15 mg bupivacaine 0.5% + 25 micrograms fentanyl was injected intrathecally.
Demographic data (age, weight, height ,duration of surgery) was measured and recorded. Assessment of heart rate, mean arterial blood pressure and peripheral oxygen saturation was continuously monitored and recorded before spinal anaesthesia, immediately after spinal anaesthesia and every 5 minutes, till the end of surgery and every hour for 6 hours postoperative.
Blood loss was measured following placental delivery till the end of the surgery and for 3 hours post operative as the sum of:
- Blood absorbed by soaked mops {wet weight of used mop – dry weight}+;
- Blood absorbed by perineal sheet during vaginal toileting {wet weight – dry weight} +;
- Blood collected in suction container.
Amniotic fluid and the volume of blood lost before placental delivery was not included in the study. One gram (gm) weight was taken as equivalent to 1ml of blood.
Haemoglobin and haematocrit levels was measured preoperative and at 12 hours post-operative.
Any side effects e.g. hypotension, nausea, vomiting, excessive bleeding and seizures etc., was reported and properly treated. All patients was examined for thromboembolic events at the 1- and 4-week follow-up visits.
Comparing the two studied groups, there were no significant differences between the two studied groups regarding age, weight, height and duration of surgery. Vital signs did not show any significant difference in between the two groups.
There was a significant decrease in the amount of blood loss in TXA group in comparison to control group. The changes between preoperative and postoperative haemoglobin and haematocrit values were significantly lower in the TXA group than in the control group. There were no significant difference in the rate of occurrence of thromboembolic events as a major side effect to TXA between the two groups. Incidence of seizures was also statistically non significant between the two studied groups. Incidence of other side effects like hypotension, nuasea and vomiting was statistically non significant between the two studied groups.