Discussion
bleeding, obese, blood loss, postoperative hemorrhage, Richardson, placenta previa accreta, hematoma
BLEEDING, POSTPARTUM HEMORRHAGE, OBESE, BLOOD LOSS, POSTOPERATIVE HEMORRHAGE, COMPLICATION, ADVERSE EFFECTS, HEMATOMA
Our study aimed to illustrate the impact of applying the tranexamic acid impregnated in a gelatin sponge between the anterior rectus sheath and the Rectus Abdominis muscle during CS in minimizing RHS in women treated with Warfarin. We found that tranexamic acid-soaked absorbable gelatin sponge reduces the incidence of rectus sheath hematoma formation and decreases the need for blood transfusion among high-risk women undergoing cesarean delivery.RHS was first reported in the literature by Richardson et al. [The ACOG committee in 2020 stated that there are limited data on the use of topical hemostatic agents in gynecologic and obstetric surgery and, therefore, recommendations are principally created upon findings extrapolated from studies on the employment of these agents in nongynecological and non-obstetric surgeries.Anticoagulant use has been recognized as the most commonly described risk factor for RSH. Despite that, many trials assessed the efficacy of tranexamic acid in preventing postpartum hemorrhage. To our knowledge, none particularly evaluated its role in patients undergoing CS treated with postnatal Warfarin or its combination (Impregnation) in gelatin sponge to minimize its theoretical systemic adverse effects, especially in high-risk predisposed patients. Therefore, the strength of this randomized control trial is not only that it is the first study to evaluate this simple tool and deal with a serious complication that may occur in those high-risk predisposed cases.Intravenous use of tranexamic acid following major surgery reduced the requirement for blood transfusion by 32–37% and postoperative hemorrhage by about 34% [We found out that tranexamic acid-soaked gelatin sponges in Group 1 (combined group) aided in a statistically significant lower EBL when compared to either the gelatin sponge alone group (In agreement with our results, Liang et al. [In addition, Ausen et al. [Nonetheless, their study had weaknesses as it was conducted on patients with a surgical procedure not usually accompanied by major bleeding. In addition, they measured drainage fluid volume only, not blood loss. Moreover, our study had a larger sample size and higher bleeding risk patients. However, both studies lacked drain fluid laboratory analysis and serum tranexamic acid concentration measurements.Shady et al. [Another study conducted by Raga et al. [The strength of our study is that we combined these concepts using tranexamic acid and an absorbable gelatin sponge placed in the space between Rectus Abdominis and the rectus sheath in pregnant women treated with Warfarin and undergoing CS. On the contrary, the study’s limitations included the relatively small sample size and that the study was restricted to patients undergoing elective CS, excluding obese patients and women with a high risk of massive obstetric bleeding, such as in cases of placenta previa accreta spectrum. Furthermore, we had not undergone laboratory analysis of the drainage fluid, which usually consists of blood and exudates, and we had not measured serum tranexamic acid in patients involved in the study.