Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial

Background Post-partum haemorrhage is the leading cause of maternal death worldwide. Early administration of tranexamic acid reduces deaths due to bleeding in trauma patients. We aimed to assess the effects of early administration of tranexamic acid on death, hysterectomy, and other relevant outcomes in women with post-partum haemorrhage. Methods In this randomised, double-blind, placebo-controlled trial, we recruited women aged 16 years and older with a clinical diagnosis of post-partum haemorrhage after a vaginal birth or caesarean section from 193 hospitals in 21 countries. We randomly assigned women to receive either 1 g intravenous tranexamic acid or matching placebo in addition to usual care. If bleeding continued after 30 min, or stopped and restarted within 24 h of the first dose, a second dose of 1 g of tranexamic acid or placebo could be given. Patients were assigned by selection of a numbered treatment pack from a box containing eight numbered packs that were identical apart from the pack number. Participants, care givers, and those assessing outcomes were masked to allocation. We originally planned to enrol 15 000 women with a composite primary endpoint of death from all-causes or hysterectomy within 42 days of giving birth. However, during the trial it became apparent that the decision to conduct a hysterectomy was often made at the same time as randomisation. Although tranexamic acid could influence the risk of death in these cases, it could not affect the risk of hysterectomy. We therefore increased the sample size from 15 000 to 20 000 women in order to estimate the effect of tranexamic acid on the risk of death from post-partum haemorrhage. All analyses were done on an intention-to-treat basis. This trial is registered with ISRCTN76912190 (Dec 8, 2008); ClinicalTrials.gov, number NCT00872469; and PACTR201007000192283. Findings Between March, 2010, and April, 2016, 20 060 women were enrolled and randomly assigned to receive tranexamic acid (n=10 051) or placebo (n=10 009), of whom 10 036 and 9985, respectively, were included in the analysis. Death due to bleeding was significantly reduced in women given tranexamic acid (155 [1·5%] of 10 036 patients vs 191 [1·9%] of 9985 in the placebo group, risk ratio [RR] 0·81, 95% CI 0·65–1·00; p=0·045), especially in women given treatment within 3 h of giving birth (89 [1·2%] in the tranexamic acid group vs 127 [1·7%] in the placebo group, RR 0·69, 95% CI 0·52–0·91; p=0·008). All other causes of death did not differ significantly by group. Hysterectomy was not reduced with tranexamic acid (358 [3·6%] patients in the tranexamic acid group vs 351 [3·5%] in the placebo group, RR 1·02, 95% CI 0·88–1·07; p=0·84). The composite primary endpoint of death from all causes or hysterectomy was not reduced with tranexamic acid (534 [5·3%] deaths or hysterectomies in the tranexamic acid group vs 546 [5·5%] in the placebo group, RR 0·97, 95% CI 0·87-1·09; p=0·65). Adverse events (including thromboembolic events) did not differ significantly in the tranexamic acid versus placebo group. Interpretation Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset. Funding London School of Hygiene & Tropical Medicine, Pfizer, UK Department of Health, Wellcome Trust, and Bill & Melinda Gates Foundation

Anomalous origin of the left coronary artery from the main pulmonary artery

The anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital heart anomaly; this occurs in 1/300,000 live births. ALCAPA syndrome was first described in 1933 by Bland and co-authors in autopsy specimens; however, further description of its clinical manifestations resulted in the naming of Bland–White–Garland syndrome. The case of a 2-year-old boy who was referred for echocardiographic investigation due to recurrent cough, catarrh, and occasional noisy breathing is reported in this communication; his chest X-ray was normal, while electrocardiogram showed Q-waves on limb leads I and aVL and the echocardiographic study showed ALCAPA

Teething myths among health workers in a tertiary health facility

Background: The teething process is part of normal development of the skeletal system; however, different tribes and ethnic groups seem to have a list of symptoms they believe are linked to teething. Could it be that health professionals also hold to these false believes concerning teething? This is important to find out because when systemic problem is misdiagnosed as teething and nothing is done, it may result in death. This study aims to assess the level of knowledge of infants' teething and associated myths among health professionals, to ascertain the attitude of health professionals toward teething in infants, and to identify practices by health professional toward “teething problems.” Materials and Methods: This study was cross-sectional study, conducted from August to September 2016, and multistage sampling method was adopted. Results: Four hundred and fifty health workers participated in the study; however, 427 of them correctly completed the questionnaire giving a response rate of 94.9%. There were 213 (49.9%) males and 214 (50.1%) females with m:f ratio of 1:1. Most respondents (322; 77.8%) believed teething was associated with significant systemic symptoms, 92 (21.5%) did not associate teething with any significant systemic complaint, while only 3 (0.7%) of them were not sure if teething causes systemic illness. Fever and loss of appetite were the most common symptoms associated with teething followed by stooling while skin rash was the least common complaint associated with teething. Conclusion: Teething myths are still prevalent among health-care workers; common illnesses attributed to teething included fever, loss of appetite, excessive salivation, and diarrhea