Introduction: Severe postpartum hemorrhage (PPH) is the main cause of death in
Tunisia. Its management is multidisciplinary and requires perfect knowledge of
a regularly updated protocol and consistent with available resources. We
propose an evaluation of the impact of different therapeutic attitudes, in
particular the combination of tranexamic acid and fibrinogen concentrates in
the management of this hemorrhage. Material and Methods: This was a
retrospective, descriptive and analytical study, conducted in the departments
of Gynecology-Obstetrics and Surgical Resuscitation anesthesia of the Farhat
Hached University Hospital, Sousse, Tunisia. The study was conducted over six
years (2009-2014), and included all parturients who were treated for severe PPH
that occurred on a term greater than 24 weeks of amenorrhea. Patients were
divided into two groups according to the study period: 1) Group
1 (G1): from 1 January 2009 to 31 December 2011, 2) Group
2 (G2): from January 1, 2012 to December 31, 2014, a group that benefited
particularly from the combination of tranexamic acid and fibrinogen concentrates
for the management of their PPH. Results: 166 patients were included: 57
in G1 and 109 in G2. The overall incidence of severe PPH was 3.15/1000
deliveries. We noted a significant decrease in the fall of hemoglobin in per
and post haemorrhagic manifestations in favor of G2 with a p value of 0.003 and p = 0.025, respectively. The use of blood transfusion decreased significantly, in frequency and
in number of packed red cells per patient, between the two groups; transfusion
ratio was 1/1.7/1.5 for G1, and 1/2/1.8 for G2. Fluid therapy, use of
macromolecules and catecholamines were less important in G2. The use of
tranexamic acid, fibrinogen and the association of both increased significantly
between the two groups (p<10-4). Haemostasis hysterectomies were less performed (p
References
[1]
Bose, P., Regan, F. and Paterson-Brown, S. (2006) Improving the Accuracy of Estimated Blood Loss at Obstetric Haemorrhage Using Clinical Reconstructions. BJOG, 113, 919-924. https://doi.org/10.1111/j.1471-0528.2006.01018.x
[2]
American College of Obstetricians and Gynecologists (2006) ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 76, October 2006: Postpartum Haemorrhage. Obstetrics and Gynecology, 108, 1039-1047.
[3]
EPIMOMS. Définition de la morbidité maternelle sévère.
https://www.prevention-medicale.org/Actualites-et-revues-de-presse/Toutes-les-actualites/Sage-femme/epidemiologie-morbidite-maternelle
[4]
HAS. Recommandations pour la pratique clinique. Hémorragies du post-partum immédiat.
http://www.hassante.fr/portail/upload/docs/application/pdf/HPP_recos.pdf
[5]
Waterstone, M., Bewley, S. and Wolfe, C. (2001) Incidence and Predictors of Severe Obstetric Morbidity: Case-Control Study. BMJ, 322, 1089-1093.
https://doi.org/10.1136/bmj.322.7294.1089
[6]
Deneux-Tharaux, C., Dupont, C., Colin, C., Rabilloud, M., Touzet, S., Lansac, J., et al. (2010) Multifaceted Intervention to Decrease the Rate of Severe Postpartum Haemorrhage: The PITHAGORE6 Cluster-Randomised Controlled Trial. BJOG, 117, 1278-1287. https://doi.org/10.1111/j.1471-0528.2010.02648.x
[7]
Callaghan, W.M., Kuklina, E.V. and Berg, C.J. (2010) Trends in Postpartum Hemorrhage: United States, 1994-2006. American Journal of Obstetrics & Gynecology, 202, 353.e1-353.e6. https://doi.org/10.1016/j.ajog.2010.01.011
[8]
Cameron, C.A., Roberts, C.L., Olive, E.C., Ford, J.B. and Fischer, W.E. (2006) Trends in Postpartum Haemorrhage. Australian and New Zealand Journal of Public Health, 30, 151-156. https://doi.org/10.1111/j.1467-842X.2006.tb00109.x
[9]
Gilstrap, L.C.I., Hauth, J.C.M., Hankins, G.D.V.M. and Patterson, A.R.M. (1987) Effect of Type of Anesthesia on Blood Loss at Cesarean Section. Obstetrics & Gynecology, 69, 328-332.
[10]
Al-Zirqi, I., Vangen, S., Forsen, L. and Stray-Pedersen, B. (2009) Effects of Onset of Labor and Mode of Delivery on Severe Postpartum Hemorrhage. American Journal of Obstetrics & Gynecology, 201, 273.e1-273.e9.
https://doi.org/10.1016/j.ajog.2009.06.007
[11]
Belghiti, J., Kayem, G., Dupont, C., Rudigoz, R.C., Bouvier-Colle, M.H. and Deneux-Tharaux, C. (2011) Oxytocin during Labour and Risk of Severe Postpartum Haemorrhage: A Population-Based, Cohort-Nested Case-Control Study. BMJ Open, 1, e000514. https://doi.org/10.1136/bmjopen-2011-000514
[12]
Grotegut, C.A., Paglia, M.J., Johnson, L.N., Thames, B. and James, A.H. (2011) Oxytocin Exposure during Labor among Women with Postpartum Hemorrhage Secondary to Uterine Atony. American Journal of Obstetrics and Gynecology, 204, 56.e1-56.e6. https://doi.org/10.1016/j.ajog.2010.08.023
[13]
Dupont, C., Rudigoz, R.C., Cortet, M., et al. (2014) Frequency, Causes and Risk Factors of Postpartum Haemorrhage: A Population-Based Study in 106 French Maternity Units. Journal de Gynécologie Obstétrique et Biologie de la Reproduction (Paris), 43, 244-253. https://doi.org/10.1016/j.jgyn.2013.05.003
[14]
Alamia Jr., V. and Meyer, B.A. (1999) Peripartum Hemorrhage. Obstetrics and Gynecology Clinics of North America, 26, 385-398.
https://doi.org/10.1016/S0889-8545(05)70081-4
[15]
Hiippala, S.T., Myllyla, G.J. and Vahtera, E.M. (1995) Hemostatic Factors and Replacement of Major Blood Loss With Plasma-Poor Red Cell Concentrates. Anesthesia and Analgesia, 81, 360-365.
[16]
Charbit, B., Mandelbrot, L., Samain, E., Baron, G., Haddaoui, B., Keita, H., et al. (2007) The Decrease of Fibrinogen Is an Early Predictor of the Severity of Postpartum Hemorrhage. Journal of Thrombosis and Haemostasis, 5, 266-273.
https://doi.org/10.1111/j.1538-7836.2007.02297.x
[17]
Cortet, M., Deneux-Tharaux, C., Dupont, C., Colin, C., Rudigoz, R., Bouvier-Colle, Mh., et al. (2012) Association between Fibrinogen Level and Severity of Postpartum Haemorrhage: Secondary Analysis of a Prospective Trial. British Journal of Anaesthesia, 108, 984-989. https://doi.org/10.1093/bja/aes096
[18]
Association of Anaesthetists of Great Britain and Ireland, Thomas, D., Wee, M., Clyburn, P., et al. (2010) Blood Transfusion and the Anaesthetist: Management of Massive Haemorrhage. Anaesthesia, 65, 1153-1161.
https://doi.org/10.1111/j.1365-2044.2010.06538.x
[19]
UK Blood Transfusion & Tissue Transplantation Services (2007) The Handbook for Transfusion Medicine.
https://www.transfusionguidelines.org/transfusion-handbook
[20]
Rossaint, R., Bouillon, B., Cerny, V., Coats, T.J., Duranteau, J., Fernandez Mondejar, E., et al. (2010) Management of Bleeding Following Major Trauma: An Updated European Guideline. Critical Care, 14, R52. https://doi.org/10.1186/cc8943
[21]
Novikova, N. and Hofmeyr, G.J. (2010) Tranexamic Acid for Preventing Postpartum Haemorrhage. Cochrane Database of Systematic Reviews, 7, CD007872.
[22]
Henry, D.A., Carless, P.A., Moxey, A.J., et al. (2007) Anti-Fibrinolytic Use for Minimising Perioperative Allogeneic Blood Transfusion. Cochrane Database of Systematic Reviews, 3, CD001886.
[23]
Ker, K., Edwards, P., Perel, P., Shakur, H. and Roberts, I. (2012) Effect of Tranexamic Acid on Surgical Bleeding: Systematic Review and Cumulative Meta-Analysis. BMJ, 344, e3054.
[24]
CRASH-2 Trial Collaborators (2010) Effects of Tranexamic Acid on Death, Vascular Occlusive Events, and Blood Transfusion in Trauma Patients with Significant Haemorrhage (CRASH-2): A Randomised, Placebo-Controlled Trial. The Lancet, 376, 23-32. https://doi.org/10.1016/S0140-6736(10)60835-5
[25]
Yang, H., Zheng, S. and Shi, C. (2001) Clinical Study on the Efficacy of Tranexamic Acid in Reducing Postpartum Blood Lose: A Randomized, Comparative, Multicenter Trial. Chinese Journal of Obstetrics and Gynecology, 36, 590-592.
[26]
Gungorduk, K., Asicioglu, O., Yildirim, G., Ark, C., Tekirdag, A.I. and Besimoglu, B. (2013) Can Intravenous Injection of Tranexamic Acid Be Used in Routine Practice with Active Management of the Third Stage of Labor in Vaginal Delivery? A Randomized Controlled Study. American Journal of Perinatology, 30, 407-413.
[27]
Gai, M.Y., Wu, L.F., Su, Q.F. and Tatsumoto, K. (2004) Clinical Observation of Blood Loss Reduced by Tranexamic Acid during and after Caesarian Section: A Multi-Center, Randomized Trial. European Journal of Obstetrics & Gynecology and Reproductive Biology, 112, 154-157.
https://doi.org/10.1016/S0301-2115(03)00287-2
[28]
Gungorduk, K., Yildirim, G., Asicioglu, O., Gungorduk, O.C., Sudolmus, S. and Ark, C. (2011) Efficacy of Intravenous Tranexamic Acid in Reducing Blood Loss after Elective Cesarean Section: A Prospective, Randomized, Double-Blind, Placebo-Controlled Study. American Journal of Perinatology, 28, 233-240.
https://doi.org/10.1055/s-0030-1268238
[29]
Shahid, A. and Khan, A. (2013) Tranexamic Acid in Decreasing Blood Loss during and after Caesarean Section. Journal of the College of Physicians and Surgeons Pakistan, 23, 459-462.
[30]
Xu, J., Gao, W. and Ju, Y. (2013) Tranexamic Acid for the Prevention of Postpartum Hemorrhage after Cesarean Section: A Double-Blind Randomization Trial. Archives of Gynecology and Obstetrics, 287, 463-468.
https://doi.org/10.1007/s00404-012-2593-y
[31]
Shakur, H., Elbourne, D., Gulmezoglu, M., Alfirevic, Z., Ronsmans, C., Allen, E., et al. (2010) The WOMAN Trial (World Maternal Antifibrinolytic Trial): Tranexamic Acid for the Treatment of Postpartum Haemorrhage: An International Randomised, Double Blind Placebo Controlled Trial. Trials, 11, 40.
https://doi.org/10.1186/1745-6215-11-40
[32]
Ducloy-Bouthors, A.S., Jude, B., Duhamel, A., Broisin, F., Huissoud, C., et al. (2011) High Dose Tranexamic Acid Reduces Blood Loss in Post Partum Hemorrhage. Critical Care, 15, R117. https://doi.org/10.1186/cc10143
[33]
Salvat, J., Schmidt, M.H., Guilbert, M. and Martino, A. (2002) Vascular Ligation for Severe Obstetrical Hemorrhage: Review of the Literature. Journal de Gynecologie, Obstetrique et Biologie de la Reproduction, 31, 629-639.
