Discussion
blood loss, bleeding, Abdelazim, blood clots
BLEEDING, POSTPARTUM HEMORRHAGE, POST-OPERATIVE HEMORRHAGE, BLOOD LOSS, BLOOD CLOTS, PLACENTAL SEPARATION, ADVERSE EFFECTS, SECONDARY, ADHESION, PATHOGENESIS, POSTOPERATIVE THROMBOSIS
The prevalence of CS is increasing worldwide, and the average obstetric bleeding during or after CS is twice the amount lost in vaginal delivery [The current randomized control trial demonstrated that the administration of both tranexamic acid and ethamsylate just before elective or emergency CS was significantly more effective in decreasing maternal bleeding than saline. However, their efficacy was relatively equal to oxytocin as no statistically significant difference was detected between them.Limited studies focused on the efficacy of the combined tranexamic acid and ethamsylate versus oxytocin in reducing blood loss during and after CS. First, a similar trial carried out in Egypt by Abdelazim et al. [In addition, our secondary findings showed that tranexamic acid with etamsylate slightly lowered the need for blood transfusion. Postoperative Hb and HCT measures were slightly higher in the tranexamic acid with ethamsylate group than in the oxytocin and saline groups. Our findings also showed that tranexamic acid with ethamsylate had milder adverse effects than oxytocin. However, all of these results were not statistically significant except for postoperative thrombosis which was significantly increased in the tranexamic and ethamsylate group.Some relevant studies discussed similar outcomes of the combined tranexamic acid and ethamsylate versus oxytocin. Abdelazim et al. [In Hassan et al. 2020, the results showed that tranexamic acid infusion reduced the necessity for additional ecbolic agents or blood transfusion [In addition, Alanwar and Gamal et al. 2020. revealed that intraoperative intravenous tranexamic acid together with ethamsylate before elective CS was effective in decreasing the need for additional uterotonic medicines postoperatively compared to placebo [Therefore, those relevant studies' findings were consistent with our study's results. Nevertheless, our study was also superior to theirs regarding the sample size (A previous meta-analysis with nine randomized control trials evaluated the effect of tranexamic acid in reducing bleeding volume when administrated before CS and demonstrated that prophylactic tranexamic acid was associated with a significant drop in post-operative bleeding amount, a significantly lower risk of postpartum hemorrhage, significantly lower levels of hemoglobin, and a significantly less need for further additional ecbolic drugs and blood transfusion, than placebo [In another study performed by Abdelaleem et al., the analysis detected that administration of intravenous oxytocin infusion before uterine incision played a significant role in reducing the volume of intra-operative blood loss and the need for additional ecbolic drugs, which was consistent with our results [Authors explained the exact pathogenesis of postpartum or post-operative hemorrhage that when the placental separation from the uterine wall takes place during delivery, fibrinolysis is activated and raises in the maternal blood, leading to the degradation of blood clots [Tranexamic acid – a synthetic lysine analogue and antifibrinolytic– competitively inhibits the binding of plasminogen and plasmin to fibrin, thus preventing this fibrinolytic activity and controlling bleeding [Ethamsylate is a hemostatic and antihemorrhagic drug that acts in the primary stage of hemostasis by raising capillaries' resistance and promoting platelet adhesion and hence decreasing bleeding [We administrated tranexamic acid with ethamsylate before the skin incision to control fibrinolysis which was after the expeditious release of tissue plasminogen activator immediately after incision [