Management of surgery, menorrhagia and child-birth for patients with unclassified bleeding disorders: a systematic review of cohort studies

Haemostasis and Thrombosis Centre, Guy's and St Thomas' NHS Foundation Trust, London Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust Radcliffe Department of Medicine, University of Oxford, Oxford Cardiff Haemophilia Centre, University Hospital of Wales Comprehensive Care Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham Systematic Review Initiative, NHS Blood and Transplant, Oxford Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.

Blood coagulation & fibrinolysis : an international journal in haemostasis and thrombosis. 2021
PICO Summary

Population

Patients with unclassified bleeding disorders undergoing surgery, childbirth or with menorrhagia (2 studies, n= 157).

Intervention

Systematic review and meta-analysis to determine the bleeding rates associated with tranexamic acid (TXA), desmopressin, platelet transfusion, plasma transfusion and recombinant activated factor VII.

Comparison

Outcome

The pooled risk of minor bleeding for patients undergoing surgery treated with peri-operative TXA was 11%; the risk for desmopressin and TXA in combination was 3%. There were no instances of major bleeding. There were too few patients treated to prevent postpartum haemorrhage or for menorrhagia. The GRADE quality of evidence was very low suggesting considerable uncertainty over the results. However, both TXA, and the combination of TXA and desmopressin have high rates of haemostatic efficacy and have few adverse events.
Abstract
Unclassified bleeding disorders account for 2.6% of all new bleeding disorder registrations in the UK. The management of the bleeding phenotype associated with these disorders is poorly described. Systematic review and meta-analysis to determine the bleeding rates associated with tranexamic acid, desmopressin, platelet transfusion, plasma transfusion and recombinant activated factor VII, for patients with unclassified bleeding disorders undergoing surgery, childbirth or with menorrhagia. We searched for randomized controlled trials in MEDLINE, Embase, The Cochrane Central Register of Controlled Trials, PubMed, ISI Web of Science and the Transfusion Evidence Library from inception to 24 February 2020. Wherever appropriate, data were pooled using the metaprop function of STATA. Two studies with 157 participants with unclassified bleeding disorders were identified. The pooled risk of minor bleeding for patients undergoing surgery treated with peri-operative tranexamic acid was 11% (95% confidence interval 3--20%; n = 52; I2 = 0%); the risk for desmopressin and tranexamic acid in combination was 3% (95% confidence interval 0--7%; n = 71; I2 = 0%). There were no instances of major bleeding. In one procedure, 1 of 71 (1.4%), treated with a combination of desmopressin and tranexamic acid, the patient had a line-related deep vein thrombosis. There were too few patients treated to prevent postpartum haemorrhage or for menorrhagia to draw conclusions. The GRADE quality of evidence was very low suggesting considerable uncertainty over the results. However, both tranexamic acid, and the combination of tranexamic and desmopressin have high rates of haemostatic efficacy and have few adverse events. PROTOCOL REGISTRATION PROSPERO CRD42020169727.
Study details
Study Design : Systematic Review
Language : eng
Credits : Bibliographic data from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine