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Shock Management
Published in Ian Greaves, Keith Porter, Jeff Garner, Trauma Care Manual, 2021
Ian Greaves, Keith Porter, Jeff Garner
Tranexamic acid is an anti-fibrinolytic agent and reduces bleeding by inhibiting the breakdown of fibrin clots. Administration of tranexamic acid within 3 hours of bleeding reduces deaths from bleeding in patients with trauma and post-partum haemorrhage.43–46 Recent meta-analysis has confirmed that tranexamic acid improves survival, but treatment delay reduces the benefit. Every 15 minutes of treatment delay appears to decrease the treatment benefit by about 10% with no benefit after 3 hours.
Postoperative Bleeding
Published in Stephen M. Cohn, Alan Lisbon, Stephen Heard, 50 Landmark Papers, 2021
We obtained funding support from the UK National Institute for Health Research (NIHR). The trial required a huge effort from hundreds of doctors and nurses around the world, but it was worth it. A total of 20,211 patients were recruited from 274 hospitals in 40 countries. The results showed that TXA reduces mortality with no apparent increase in side effects. If given promptly, the TXA reduces the risk of bleeding to death by about a third. On the basis of these results, it has been estimated that giving TXA to bleeding trauma patients could save up to 200,000 lives per year worldwide. Cost-effectiveness analysis showed that TXA administration is highly cost effective in high, middle, or low income countries. On the basis of the trial results, tranexamic acid was included on the WHO List of Essential Medicines and incorporated into trauma treatment guidelines in many countries. Tranexamic acid is a cheap, generic drug but has huge potential to save lives. We are fortunate to live in a country where you can obtain public funds for patient centered research despite there being little commercial interest from the pharmaceutical industry.
Secondary Hemorrhage after Myomectomy
Published in Rooma Sinha, Arnold P. Advincula, Kurian Joseph, FIBROID UTERUS Surgical Challenges in Minimal Access Surgery, 2020
As a dictum, when a patient presents with severe bleeding, management includes hemodynamic resuscitation, stabilization, and control of the source of bleeding. Tranexamic acid can be tried initially for control of bleeding. If bleeding does not respond to conservative approaches, conventional surgery and pelvic angioembolization must be kept in mind. As evidence suggests, for any patient with secondary hemorrhage after myomectomy (hysteroscopic, laparotomy, or laparoscopic), a high index of suspicion for a pseudoaneurysm must be kept in mind. On ultrasonography, a pseudoaneurysm appears like a well-defined hypoechoic/anechoic cystic structure which may be associated with a hematoma at the previous myomectomy site [16] with turbulent blood flow on color Doppler. However, 3D computed tomography (CT) angiography is the preferred modality for a more accurate diagnosis of a pseudoaneurysm [17]. Once the diagnosis of a pseudoaneurysm has been established, management by transarterial embolization of the pseudoaneurysm should be discussed in detail with the patient [15–20]. Even in the absence of a pseudoaneurysm, if there is an obvious bleeder on angiography, embolization of the uterine artery has been shown to be a safe and effective method in stopping hemorrhage from its pseudoaneurysm/bleeding branch, as shown in various past studies. At the time of embolization, it is important that along with all the major feeding vessels, collateral supply from the opposite uterine artery is also taken care of to prevent a recurrence and rebleed.
Diagnosis and medical management of abnormal premenopausal and postmenopausal bleeding
Published in Climacteric, 2023
Women with heavy menstrual bleeding have been shown to have elevated levels of plasminogen activators compared to women with normal menstrual bleeding [21]. Tranexamic acid is an inhibitor of plasminogen activators, so has a role in management of heavy menstrual bleeding. The NICE advocates for use of tranexamic acid and/ or non-steroidal anti-inflammatory drugs while investigations and definitive therapy are being organized, and for as long as it is beneficial [6]. There is some disagreement as to whether or not tranexamic acid may be used as an adjunct to combined hormonal contraceptives in management of heavy menstrual bleeding: in the USA, current use of combined hormonal contraceptives is listed as a contraindication to concurrent use of tranexamic acid. There is little evidence in the literature to support this [22].
Safety of medications for hereditary angioedema during pregnancy and lactation
Published in Expert Opinion on Drug Safety, 2023
Andrew Yeich, Ahmed Elhatw, Zaynab Ashoor, Kristen Park, Timothy Craig
For LTP, androgens are essential to avoid, and though used in some countries, the safety of tranexamic acid use during pregnancy and lactation has not been established. However, the authors believe that the risk benefit ratio for tranexamic acid, in severe cases of HAE during pregnancy, when no others therapies are available, may be justified. More case reports of outcomes are essential so that objective evidence of safety become available. Naturally, the ideal solution would involve more widespread availability of first line treatment. More data are needed on newly approved medications, including berotralstat and lanadelumab, before recommending use during pregnancy and lactation. Along with lanadelumab, other soon to be approved monoclonal therapies indicated for long-term prophylaxis will need to be studied further before use in this unique population. The concern with some new and ‘in research’ monoclonal therapies is that since IgG crosses the placenta, and inhibits bradykinin production, will there be consequences to the fetus. Further studies are needed to establish if the contact pathway is essential for the development of a healthy fetus.
Immune thrombocytopenia
Published in Expert Review of Hematology, 2021
James Bussel, Nichola Cooper, Ralph Boccia, Francesco Zaja, Adrian Newland
Recent ICR guidelines for ITP in emergency treatment, patients failing multiple therapies as well as pregnancy are outlined in Box 2 [23]. For emergency treatment, TPO-RAs should be considered in a patient receiving corticosteroids with life-threatening bleeding and absence of a significant response to IVIg and platelet transfusion. Although there are many options for patients failing several therapies, there is very little reliable data in pregnancy. Furthermore, toxicity to the fetus is understood and is low. Azathioprine, cyclosporin and rituximab are all thought to be relatively safe for the fetus although rituximab may induce late (after 3 months from birth) hypogammaglobulinemia in the infant. Supportive care is an important option using tranexamic acid for patients who are bleeding.