Prophylactic effect of misoprostol versus tranexamic acid in conjunction with oxytocin in reduction of post-partum hemorrhage after cesarean sectionin: A randomized clinical trial

authors:

avatar Sanam Moradan , avatar Roya Mahdavi Anaraki , avatar Majid Mirmohammadkhani ORCID , *


how to cite: Moradan S, Mahdavi Anaraki R, Mirmohammadkhani M. Prophylactic effect of misoprostol versus tranexamic acid in conjunction with oxytocin in reduction of post-partum hemorrhage after cesarean sectionin: A randomized clinical trial. koomesh. 2018;20(4):e153002. 

Abstract

Introduction: Postpartum hemorrhage is an important complication and is a direct cause of maternal death and its effective prevention has a significant role in reducing complications, especially maternal mortality. In this way, the purpose of this study was to compare the prophylactic effect of the addition of misoprostol and transxamic acid to oxytocin in reducing postpartum hemorrhage after cesarean section. Materials and Methods: In a clinical trial, 285 pregnant women with gestational age of 38 to 39 weeks candidates for elective cesarean section enrolled in the study and were randomly assigned to three groups. After spinal anesthesia and cesarean section, immediately after clamping of the umbilical cord, patients in the first group received misoprostol 400 mcg rectal, patients in the second group received 10 mg/Kg tranexamic acid by intravenous infusion. First and second groups (as intervention groups) and third one (as control group) all received 30 units oxytocin during operation and 60 units within 12 hours after the section. Counting the gases was performed after the operation and measuring hematocrit levels 24 hours later. Results: The mean± SD of age was 29.72 ± 3.8 years and was not significantly different in the three groups (P = 0.171) and 246 participants (84.4%) came for their second parity. The studied groups did not differ in parity number (p = 0.170).  The average number of consumpted gauzes was 6.99. Three groups were different in terms of consumpted gauzes during section (p < 0.001). Mean of hematocrit before and after intervention showed significant differences in the three groups (p < 0.001). Intervention groups have a better effect on bleeding compared to control one in terms of hematocrit changes (p < 0.001), however, two misoprostol and tranexamic acid drugs showed no difference  in reducing it (p = 0.117). Conclusion: Adding each of the misoprostol or tranzamic acid to oxytocin alone has a better effect in reducing bleeding alone, but since the therapeutic effects of these two drugs are similar, it is necessary to select the drug according to the patient;#39s clinical condition and possible side effects of either drug

References

  • 1.

    Cantwell R, Clutton-Brock T, Cooper G, Dawson A, Drife J, Garrod D, et al. Saving Mothers' lives: reviewing maternal deaths to make motherhood safer: 2006-2008. the eighth report of the confidential enquiries into maternal deaths in the united kingdom. BJOG 2011; 118: 1-203.

  • 2.

    F. Gary Cunningham M, Kenneth J. Leveno, MD, Steven L. Bloom, MD, Catherine Y. Spong, MD, Jodi S. Dashe, MD, Barbara L. Hoffman, MD, Brian M. Casey, MD, Jeanne S. Sheffield, MD. Williams Obstetrics, McGraw-Hill's Access Medicine. 24 ed. New York, N.Y.: McGraw Hill Medical; 2014.

  • 3.

    Chelmow D. Postpartum haemorrhage: prevention. BMJ clinical evidence 2011/04/06 ed2011.

  • 4.

    Tunalp O, Souza JP, Glmezoglu M. New WHO recommendations on prevention and treatment of postpartum hemorrhage. Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet 2013; 123: 254-256.

  • 5.

    Smith HJ, Colvin CJ, Richards E, Roberson J, Sharma G, Thapa K, Gulmezoglu AM. Programmes for advance distribution of misoprostol to prevent post-partum haemorrhage: a rapid literature review of factors affecting implementation. Health policy Plan 2016; 31: 102-113.

  • 6.

    Esteves-Pereira AP, Deneux-Tharaux C, Nakamura-Pereira M, Saucedo M0, Bouvier-Colle MH, Leal Mdo C. Caesarean delivery and postpartum maternal mortality: a population-based case control study in Brazil. PLoS One 2016; 11: e0153396.

  • 7.

    Maroufizadeh S, Bagheri Lankarani N, Esmailzadeh A, Almasi-Hashiani A, Amini P, Sepidarkish M, et al. Prevalence of cesarean section and its related factors among multiparous in Tehran province, Iran. Koomesh 2017; 19: 742-748. (Persian).

  • 8.

    Almasi-Hashiani A, Sepidarkish M, Omani-Samani R. Relationship of gestational weight gain with cesarean delivery risk, low birth weight and preterm labor in underweight women. Koomesh 2018; 20: 7-14. (Persian).

  • 9.

    Chaudhuri P, Mandi S, Mazumdar A. Rectally administrated misoprostol as an alternative to intravenous oxytocin infusion for preventing post-partum hemorrhage after cesarean delivery. J Obstet Gynaecol Res 2014; 40: 2023-2030.

  • 10.

    Gulmezoglu AM, Forna F, Villar J, Hofmeyr GJ. Prostaglandins for preventing postpartum haemorrhage. The Cochrane Database Syst Rev 2007; 3: Cd000494.

  • 11.

    Eftekhari N, Doroodian M, Lashkarizadeh R. The effect of sublingual misoprostol versus intravenous oxytocin in reducing bleeding after caesarean section. J Obstet Gynaecol 2009; 29: 633-636.

  • 12.

    Chaudhuri P, Banerjee GB, Mandal A. Rectally administered misoprostol versus intravenous oxytocin infusion during cesarean delivery to reduce intraoperative and postoperative blood loss. Int J Gynaecol Obstet 2010; 109: 25-29.

  • 13.

    Owonikoko KM, Arowojolu AO, Okunlola MA. Effect of sublingualmisoprostol versus intravenous oxytocin on reducing blood loss at cesarean section in Nigeria: a randomized controlled trial. J Obstet Gynaecol Res 2011; 37: 715-721.

  • 14.

    Conde-Agudelo A, Nieto A, Rosas-Bermudez A, Romero R. Misoprostol to reduce intraoperative and postoperative hemorrhage during cesarean delivery: a systematic review and metaanalysis. Am J Obstet Gynecol 2013; 209: 40.e1-.e17.

  • 15.

    Hua J, Chen G, Xing F, Scott M, Li Q. Effect of misoprostol versus oxytocin during caesarean section: a systematic review and meta-analysis. BJOG 2013; 120: 531-540.

  • 16.

    Kundodyiwa TW, Majoko F, Rusakaniko S. Misoprostol versus oxytocin in the third stage of labor. Int J Gynaecol Obstet 2001; 75: 235-241.

  • 17.

    Baskett TF, Persad VL, Clough HJ, Young DC. Misoprostol versus oxytocin for the reduction of postpartum blood loss. Int J Gynaecol Obstet 2007; 97: 2-5.

  • 18.

    Patted SS, Goudar SS, Naik VA, Bellad MB, Edlavitch SA, Kodkany BS, et al. Side effects of oral misoprostol for the prevention of postpartum hemorrhage: results of a community-based randomised controlled trial in rural India. J Matern Fetal Neonatal Med 2009; 22: 24-28.

  • 19.

    Gandhi R, Evans HM, Mahomed SR, Mahomed NN. Tranexamic Acid and the reduction of blood loss in total knee and hip arthroplasty: a meta-analysis. BMC Res Notes 2013; 6: 184.

  • 20.

    Hutton B, Joseph L, Fergusson D, Mazer CD, Shapiro S, Tinmouth A. Risks of harms using antifibrinolytics in cardiac surgery: systematic review and network meta-analysis of randomised and observational studies. BMJ 2012; 345: e5798.

  • 21.

    Roberts I, Shakur H, Ker K, Coats T. Antifibrinolytic drugs for acute traumatic injury. Cochrane Database Syst Rev 2012; 12: Cd004896.

  • 22.

    Heesen M, Bohmer J, Klohr S, Rossaint R, van de Velde M, Dudenhausen JW, Straube S. Prophylactic tranexamic acid in parturients at low risk for post-partum haemorrhage: systematic review and meta-analysis. Acta Anaesthesiol Scand 2014; 58: 1075-1085.

  • 23.

    Hutton B, Joseph L, Fergusson D, Mazer CD, Shapiro S, Tinmouth A. Risks of harms using antifibrinolytics in cardiac surgery: systematic review and network meta-analysis of randomised and observational studies. BMJ 2012; 345: e5798.

  • 24.

    Ferrer P, Roberts I, Sydenham E, Blackhall K, Shakur H. Anti-fibrinolytic agents in post partum haemorrhage: a systematic review. BMC Pregnancy Childbirth 2009; 9: 29.

  • 25.

    Novikova N, Hofmeyr GJ. Tranexamic Acid for preventing postpartum haemorrhage. Cochrane Database Syst Rev 2010; 7: Cd007872.

  • 26.

    Peitsidis P, Kadir RA. Antifibrinolytic therapy with Tranexamic Acid in pregnancy and postpartum. Expert Opin Pharmacother 2011; 12: 503-516.

  • 27.

    Faraoni D, Carlier C, Samama CM, Levy JH, Ducloy-Bouthors AS. [Efficacy and safety of Tranexamic Acid administration for the prevention and/or the treatment of post-partum haemorrhage: a systematic review with meta-analysis]. Ann Fr Anesth Reanim 2014; 33: 563-571.

  • 28.

    Garrigue A, Pierre F. [Misoprostol: off-label use in the treatment of post-partum hemorrhage]. J Gynecol Obstet Biol Reprod (Paris) 2014; 43: 179-189.

  • 29.

    Soleimani z, Aghazadeh Naini A. The effectiveness of sublingual misoprostol in prevention of bleeding during cesarean delivery. Iran J Obstet Gynecol Infert 2014; 17: 1-7. (Persian).

  • 30.

    Sahhaf F, Abbasalizadeh S, Ghojazadeh M, Velayati A, Khandanloo R, Saleh P, et al. Comparison effect of intravenous Tranexamic Acid and misoprostol for postpartum haemorrhage. Niger Med J 2014; 55: 348-353.

  • 31.

    McClure EM, Jones B, Rouse DJ, Griffin JB, Kamath-Rayne BD, Downs A, Goldenberg RL. Tranexamic acid to reduce postpartum hemorrhage: A MANDATE systematic review and analyses of impact on maternal mortality. Am J Perinatol 2015; 32: 469-474.