Comparative study of topical and intravenous tranexamic acid for prevention of postpartum haemorrhage in placenta praevia cesarean section

Abstract

Introduction: Topical application of tranexamic acid provides a high drug concentration at site of wound and a low systemic concentration. Intravenous tranexamic acid has been shown to be very useful in reducing blood loss and incidence of blood transfusion.Aims and Objectives: To compare topical and intravenous tranexamic acid for prevention of postpartum haemorrhage in placenta praevia cesarean section.Material and Methods: Group 1: Patients who received 1 gram (10 ml) tranexamic acid intravenous before skin incision plus 10 IU oxytocin intravenous infusion after placental delivery.Group 2: Patients who received 10 IU oxytocin intravenous infusion after placental delivery plus 2 grams (20 ml) topical tranexamic acid applied on placental bed after delivery of baby.Results: The mean age was similar in both groups i.e. 27.31 ± 5.62 years in group 1 and 28.06 ± 6.73 years in group 2. Mean body weight was 63.20 ± 6.12 kg in group 1 and 61.49 ± 6.12 kg in group 2. The mean systolic blood pressure in group 1 and 2 was 112.74 ± 8.79 and 113.49 ± 10.57 mmHg respectively, mean diastolic blood pressure was 75.37 ± 8.21 and 76.34 ± 6.70 mmHg and mean pulse rate was 91.77 ± 6.74 and 92.17 ± 7.49 per minute respectively. Maximum number of women had unscarred uterus i.e. 80% in group 1 and 77.1% in group 2. Mean pre-operative hemoglobin was 9.59 ± 1.35 g/dl in group 1 and 9.30 ± 1.33 g/dl in group 2. Mean INR was 0.99 ± 0.14 in group 1 and 0.97 ± 0.15 in group 2. The mean platelet count was 2.01 ± 0.39 lac in group 1 and 1.97 ± 0.42 lac in group 2. Only 8.6% in group 1 and 14.3% in group 2 required blood transfusion. Mean requirement of intra-operative blood transfusion was 0.457 ± 0.730 units in group 1 and 0.085 ± 0.279 units in group 2. Intra-operative mean blood loss was 464.86 ± 28.00 ml in intravenous tranexamic acid group and 420.46 ± 69.75 ml in topical tranexamic acid group. The requirement of additional uterotonics in form of misoprostol and/or carboprost was 17.1% in group 1 and 5.7% in group 2.A total of 22.9% women showed nausea and vomiting in group 1while none of the women showed nausea, vomiting or any other side-effects in topical tranexamic acid group. A total of 20% women in group 1 and 5.7% women in group 2 developed postpartum hemorrhage. Mean post-operative hemoglobin was 8.85 ± 1.26 g/dl in group 1 and 8.75 ± 1.30 g/dl in group 2. The mean decline in hemoglobin concentration was 0.734 ± 0.35 g/dl in group 1 and 0.569 ± 0.25 g/dl in group 2. Mean requirement of post-operative blood transfusion was 0.20 ± 0.575 units in group 1 and 0.057 ± 0.232 units in group 2. Mean birth weight of neonates was 2.41 ± 0.52 kg in group 1 and 2.42 ± 0.57 kg in group 2. Perinatal complications like low birth weight, NICU transfer, respiratory distress syndrome and severe birth asphyxia were not significantly different in both groups.Conclusion: From our study, it is concluded that tranexamic acid used prophylactically intravenously before skin incision or topical application on placental bed after placental delivery in patients undergoing cesarean section for placenta praevia significantly reduces intra-operative blood loss. Tranexamic acid use also reduces incidence of postpartum hemorrhage, need for blood transfusion, and need of additional uterotonics or additional surgical interventions in form of hemostatic sutures, balloon tamponade, uterine artery ligation or cesarean hysterectomy