Tranexamic Acid Effective as Prophylactic Measure for Reducing Blood Loss in Hysterectomy: IJOGR
Hysterectomy is one of the most frequently performed major gynaecological surgical procedures worldwide. Although, mostly it is performed for benign indications, a substantially high rates of complications has been reported, out of them most common complication is bleeding during perioperative period. Considering the high incidence of anaemia in India, excessive blood loss during surgery adds to delay in postoperative recovery and increase in post operative complications like wound healing.
A variety of antibrinolytic drugs has been used prophylactically to reduce perioperative blood loss such as tranexamic acid(TXA), Epsilon amino caproic acid (EACA) and Aprotinin.
Tranexamic acid is an antifibrinolytic agent approved for treatment of various types of haemorrhage. It acts by inhibiting fibrin degradation, thereby enhancing stable blood clots formation.
In several countries, the drug is used as prophylactic treatment prior to major surgery. Women undergoing hysterectomy might benefit from prophylactic Tranexamic acid during surgery. World health organisation (WHO) has added tranexamic acid in the list of Essential Medicines and for the treatment of adult patients with trauma and ongoing haemorrhage. (Selection and Use of Essential Medicines guideline - March 2011).
American society of Anesthesiologists (ASA) practice guidelines for perioperative blood management in surgical patients with excessive bleeding also recommend use of TXA.
Therefore, a study was conducted by Sapna Bajaj Jain and Shikha published in Indian Journal of Obstetrics and Gynecology Research to find out the effectiveness of tranexamic acid in reducing perioperative blood loss in patients undergoing hysterectomy as well as postoperative complications and hospital stay in study subject.
They conducted a Retrospective observational study over a period of 1 year in 200 patients. Study was conducted in Obstetrics and Gynaecology department of L.N. medical college, J.K hospital and research centre Bhopal. A retrospective analysis of all patients record was done who underwent hysterectomy for benign indications over the study period of one year and patient were sorted out in two groups, one (group 1) who received tranexamic acid (TXA) during surgery and other one (group 2) who did not receive TXA during surgery.
- The blood loss estimated in group 1 and group 2 were 412.18±103.1 ml and 585.22±138.9 ml respectively. Thus, there was a significant reduction in mean blood loss in group 1 when compared to group 2.
- There was significant fall in postoperative haemoglobin level in patients who had not received tranexamic acid injection during surgery.
- The postoperative haemoglobin measured at 24 hours postoperatively was significantly lower in group 2 when compared to group 1.
- The operating time was also significantly shorter in group 1 compared to group 2 (102.86 versus 138.64 minutes)
- Also patients in group 1 had lesser hospital stay as compared to patients in group 2 (6.32days vs 8.59 days)
- Postoperative complications were significantly less in group 1 compared to group 2
- Minor adverse effects like gastric disturbances, nausea, vomiting were noted in both the groups thus not contributing to the minor side effect of TXA. No major adverse effects were observed in both groups post operatively.
With burden of anaemia so high in India, it can be assumed that major portion of women undergoing hysterectomy are already suffering from anaemia and they have borderline haemoglobin status, heavy menstrual bleeding further adds to increase risk of anaemia in them.
Use of prophylactic antifibrinolytic drug like tranexamic acid as intravenous injection just before surgery can be adopted as one of the conservative approach to reduce blood loss during hysterectomy.
Tranexamic acid being an antifibrinolytic agent acts by blocking the lysine binding sites reversibly on plasminogen molecule and hence preventing degradation of clot. It competitively inhibits plasminogen activation.
Over a period of time various studies had been carried out to know the effect of tranexamic acid as a prophylactic measure in reducing blood loss during surgery and hence reduced need for blood transfusion.
In this study, there was significant reduction in perioperative blood loss by giving dose of 1 gm Intravenous injection of tranexamic acid during surgery (412ml vs 585ml). The reduction in blood loss contributed in lowering operating time in tranexamic acid group by providing clear operating field and better haemostasis thus reducing the operating time (102.86 minutes vs 138.64 minutes).
As far as cost-effectiveness is concerned, use of TXA is definitively more cost effective compared to blood transfusion. The incidence of postoperative complications like delayed wound healing and recovery were minimal in TXA treated group which also reduced the cost of surgery.
Minor side effects like nausea, vomiting, diarrhoea, dyspepsia and headache were noted in few patients of TXA treated group but no incidences of thromboembolic events occurred in any of the patient.
"Our findings conclude that TXA should be considered as prophylactic treatment prior to elective benign hysterectomy in order to reduce the risk of substantial bleeding and need for blood transfusion, early recovery and less hospital stay. It is especially helpful in developing countries like India where there is already a huge burden of anaemia and limited resources."
With proper consideration of contraindications of TXA, it can be used safely in elective gynaecological surgeries. Further large scale trial for prophylactic use of TXA is needed for effective utilisation of it.