Showing papers in "Journal of Maternal-fetal & Neonatal Medicine in 2020"
TL;DR: The effects of the COVID-19 pandemic on the depression and anxiety levels of pregnant women point to an urgent need to provide psychosocial support to this population during the crisis.
Abstract: Objective: The 2019 coronavirus disease (COVID-19) outbreak that began in China has turned into a pandemic that threatens global health, thereby prompting the concentration of studies and clinical routines on treating and preventing the disease. However, research on the psychological effects of the pandemic on the general population, particularly pregnant women, is lacking. Accordingly, the present study investigated the effects of the COVID-19 pandemic on depression and anxiety in pregnant women.Study design: An anonymous survey for assessing depression and anxiety in pregnant women was designed, after which a link to the online questionnaire was sent to the participants, who were being treated in a private medical center. One of the researchers followed up with the respondents, among whom 260 returned their questionnaires.Results: Among the respondents, 35.4% (n = 92, case group) obtained scores higher than 13 on the Edinburgh Postpartum Depression Scale (EPDS). The comparison of the groups by years of education indicated statistically significant effects of COVID-19 on psychology, social isolation, and mean scores in the Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI). These effects were more severe in the case group than in the control group (psychology: 8.369 ± 2.003, social isolation: 8.000 ± 2.507, mean BDI and BAI scores: 20.565 ± 6.605 and 22.087 ± 8.689, respectively). A regression analysis revealed that the BDI scores and the disease's psychological effects, as well as the BAI scores and the illness's social isolation effects, exerted a statistically significant influence on the EPDS scores of the participants.Conclusion: This study illustrated the effects of the COVID-19 pandemic on the depression and anxiety levels of pregnant women. Our results point to an urgent need to provide psychosocial support to this population during the crisis. Otherwise, adverse events may occur during pregnancy and thus affect both mother and fetus.
312 citations
TL;DR: The clinical characteristics of pregnant women with COVID-19 are similar to those of non-pregnant adults, and Fetal and neonatal outcomes appear good in most cases, but available data only include pregnant women infected in their third trimesters.
Abstract: Objective: To summarize currently available evidence on maternal, fetal, and neonatal outcomes of pregnant women infected with Coronavirus Disease 2019 (COVID-19).Material and methods: PubMed, Google Scholar, CNKI, Wanfang Data, VIP, and CBMdisc were searched for studies reporting maternal, fetal, and neonatal outcomes of women infected with COVID-19 published from 1 January 2020 to 26 March 2020. The protocol was registered with the Open Science Framework (DOI: 10.17605/OSF.IO/34ZAV).Results: In total, 18 studies comprising 114 pregnant women were included in the review. Fever (87.5%) and cough (53.8%) were the most commonly reported symptoms, followed by fatigue (22.5%), diarrhea (8.8%), dyspnea (11.3%), sore throat (7.5%), and myalgia (16.3%). The majority of patients (91%) had cesarean delivery due to various indications. In terms of fetal and neonatal outcomes, stillbirth (1.2%), neonatal death (1.2%), preterm birth (21.3%), low birth weight (<2500 g, 5.3%), fetal distress (10.7%), and neonatal asphyxia (1.2%) were reported. There are reports of neonatal infection, but no direct evidence of intrauterine vertical transmission has been found.Conclusions: The clinical characteristics of pregnant women with COVID-19 are similar to those of non-pregnant adults. Fetal and neonatal outcomes appear good in most cases, but available data only include pregnant women infected in their third trimesters. Further studies are needed to ascertain long-term outcomes and potential intrauterine vertical transmission.
198 citations
TL;DR: Evidence is provided that the COVID-19 pandemic significantly increases the risk of anxiety among women during pregnancy and perinatal period and support measures should be considered for women during pregnant or postpartum to guarantee mental health for this susceptible population.
Abstract: To evaluate the effect of the COVID-19 pandemic on anxiety and depression of women during pregnancy and perinatal period. We systematically searched online databases to identify any report on mater...
198 citations
TL;DR: Analysis of prospectively collected data yielded at a single tertiary “Coronavirus Pandemic Hospital” referral center for a ten days period following the first confirmed death due to the COVID-19 pandemic in Turkey may guide obstetricians and midwives to perceive what accurate information should be provided to the pregnant women.
Abstract: Background: COVID-19 is a novel type of the coronavirus family with an incompletely described clinical course. Little is known about the psychological aspects, particularly for vulnerable populatio...
82 citations
TL;DR: The entire placenta and the invaded area are removed in block, to guarantee to perform the uterine repair with healthy tissue and to avoid a recurrence in the subsequent cesarean.
Abstract: Objective: To describe the use of surgical repair (One-step resective-conservative surgery) in all cases of placenta accreta spectrum.Study design: Multicentre retrospective case series from tertia...
71 citations
TL;DR: Although pregnant women are at an immunosuppressive state due to the physiological changes during pregnancy, most patients suffered from mild or moderate COVID-19 pneumonia with no pregnancy loss, proposing a similar pattern of the clinical characteristics of COVID -19 pneumonia to that of other adult populations.
Abstract: Background: The new SARS-CoV-2 originated from Wuhan, China is spreading rapidly worldwide. A number of SARS-CoV-2 positive pregnant women have been reported. However, more information is still needed on the pregnancy outcome and the neonates regarding COVID-19 pneumonia.Material and Methods: A systematic search was done and nine articles on COVID-19 pneumonia and SARS-CoV-2 positive pregnant women were extracted. Some maternal-fetal characteristics were extracted to be included in the meta-analysis.Results: The present meta-analysis was conducted on 87 SARS-CoV-2 positive pregnant women. Almost 65% of the patients reported a history of exposure to an infected person, 78% suffered from mild or moderate COVID-19, 99.9% had successful termination, 86% had cough, and 68% had fever (p = .022 and p < .001). The overall proportions of vertical transmission, still birth, and neonatal death were zero, 0.002, and, 0.002, respectively (p = 1, p = .86, and p = .89, respectively). The means of the first- and fifth-minute Apgar scores were 8.86 and 9, respectively (p < .001 for both). The confounding role of history of underlying diseases with an estimated overall proportion of 33% (p = .03) resulted in further investigations due to sample size limitation. A natural history of COVID-19 pneumonia in the adult population was presented, as well.Conclusion: Currently, no evidence of vertical transmission has been suggested at least in late pregnancy. No hazards have been detected for fetuses or neonates. Although pregnant women are at an immunosuppressive state due to the physiological changes during pregnancy, most patients suffered from mild or moderate COVID-19 pneumonia with no pregnancy loss, proposing a similar pattern of the clinical characteristics of COVID-19 pneumonia to that of other adult populations.
67 citations
TL;DR: Maternal anemia during pregnancy can be considered as a risk factor for premature birth, according to a systematic review and meta-analysis performed from 1990 to 2018.
Abstract: Objective: Iron deficiency anemia is the most common cause of anemia during pregnancy. Other causes of anemia include parasitic diseases, micronutrient deficiencies, and genetic hemoglobin apathies. Maternal anemia during pregnancy is the most important public health problem. Since the relationship between maternal anemia by the months of pregnancy and premature birth has been reported differently in various studies; thus, this study aims to determine the relationship between maternal anemia during pregnancy and premature birth.Methods: This systematic review and meta-analysis article was designed based on the recommendations of PRISMA. This study was performed from 1990 to 2018. Articles extracted using related keywords such as maternal, anemia, premature birth, and pregnancy in databases, including Cochrane, Medline, Medlib, Web of Science, PubMed, Scopus, Springer, Science Direct, Embase, Google Scholar, Sid, Irandoc, Iranmedex, and Magiran. Relative risk and its confidence interval were extracted from each of the studies. The random effects model was used to combine study results and heterogeneity among the studies measured using I2 index and the data were analyzed based by using STATA software version 3.2.Results: Overall 18 studies with sample sizes of 932 090 were entered into the meta-analysis. The overall relationship between maternal anemia during pregnancy and premature birth was significant (1.56 [95% CI: 1.25-1.95]). Maternal anemia in the first trimester increases the risk of premature birth (relative risk, 1.65 [95% CI: 1.31-2.08]). But, this relationship was not significant in the second (relative risk, 1.45 [95% CI: 0.79-2.65]) and third trimester (relative risk, 1.43 [95% CI: 0.82-2.51]).Conclusion: Maternal anemia during pregnancy can be considered as a risk factor for premature birth.
65 citations
TL;DR: In December 2019, this viral disease originated as human-to-human transmissio...
Abstract: These days, the most important health challenge in the world is the outbreak of novel coronavirus (COVID-19) infection. In December 2019, this viral disease originated as human-to-human transmissio...
61 citations
TL;DR: It is essential in an emergency situation to understand what is at stake and prepare maternity wards in the best possible way and suggest quick key points of strategies to implement in obstetric units without delay to respond to the oncoming wave.
Abstract: COVID-19 is placing considerable strain on healthcare systems. Disaster and military medicine specialists were involved in the outbreak in Italy, after many units were overwhelmed. Health providers were caught off guard and personnel was unprepared to face this unprecedented threat. Local decisions accelerated the rate of the spread. Many countries declared a state of emergency and lockdown to contain the exponential transmission of the disease. The purpose of this review is to suggest quick key points of strategies to implement in obstetric units without delay to respond to the oncoming wave, based on experience and feedback from the field. It is essential in an emergency situation to understand what is at stake and prepare maternity wards in the best possible way.
59 citations
TL;DR: Barriers to access healthcare, differences in pandemic containment measures in the country and high prevalence of concomitant risk factors for COVID-19 severe disease may play a role in the observed disparity compared to worldwide reports on maternal outcomes.
Abstract: The aim of this study was to collect and analyze data from different sources to have a general overview of COVID-19-related maternal deaths in Brazil, as well as to compare data with worldwide repo...
59 citations
TL;DR: Obesity, age >35 years, smoking before or during pregnancy, placenta previa, prior cesarean section (CS), placentA previa and prior CS, prior uterine surgery, abortion and uterine curettage, in vitro fertilization (IVF) pregnancy and interval between a previous CS, and a subsequent pregnancy were explored.
Abstract: Purpose of the article. To explore the strength of association between different maternal and pregnancy characteristics and the occurrence of abnormally invasive placenta (AIP).Materials and methods: Pubmed, Embase, CINAHL databases were searched. The risk factors for AIP explored were: obesity, age >35 years, smoking before or during pregnancy, placenta previa, prior cesarean section (CS), placenta previa and prior CS, prior uterine surgery, abortion and uterine curettage, in vitro fertilization (IVF) pregnancy and interval between a previous CS, and a subsequent pregnancy. Random-effect head-to-head meta-analyses were used to analyze the data.Results: Forty-six were included in the systematic review. Maternal obesity (Odd ratio, OR: 1.4, 95% CI 1.0-1.8), advanced maternal age (OR: 3.1, 95% CI 1.4-7.0) and parity (OR: 2.5, 95% CI 1.7-3.6), but not smoking were associated with a higher risk of AIP. The presence of placenta previa in women with at least a prior CS was associated with a higher risk of AIP compared to controls, with an OR of 12.0, 95% CI 1.6-88.0. Furthermore, the risk of AIP increased with the number of prior CS (OR of 2.6, 95% CI 1.6-4.4 and 5.4, 95% CI 1.7-17.4 for two and three prior CS respectively). Finally, IVF pregnancies were associated with a high risk of AIP, with an OR of 2.8 (95% CI 1.2-6.8).Conclusion: A prior CS and placenta previa are among the strongest risk factors for the occurrence of AIP.
TL;DR: Black women were at higher risk for severe morbidity and mortality associated with preeclampsia than non-Hispanic white, Hispanic, and all other women, compared by race.
Abstract: Objective: The objective of this study was to assess how race is associated with adverse maternal outcomes in the setting of preeclampsia.Study design: This retrospective cohort study utilized the ...
TL;DR: Promoting breastfeeding, reducing the length of hospital stay, and reducing unnecessary antibiotic therapies are useful strategies to counterbalance unintended effects of these conditions.
Abstract: There is an increasing evidence that the intestinal microbiota plays a pivotal role in the maturation of the immune system and in the prevention of diseases occurring during the neonatal period, childhood, and adulthood. A number of nonphysiological conditions during the perinatal period (i.e. caesarean section, prolonged hospitalization, formula feeding, low gestational age) may negatively affect the normal development of the microbiota, leading to decreased amounts of lactobacilli and bifidobacteria and increased amounts of Clostridia. In addition, perinatal antibiotics can cause intestinal dysbiosis that has been associated with short- and long-term diseases. For example, prolonged early empiric antibiotics increase the risk of necrotizing enterocolitis (NEC) and late-onset sepsis (LOS) in preterm neonates, whereas the administration of intrapartum antibiotic prophylaxis (IAP) has been associated with inflammatory bowel diseases, obesity, and atopic conditions, such as eczema and wheezing. Promoting breastfeeding, reducing the length of hospital stay, and reducing unnecessary antibiotic therapies are useful strategies to counterbalance unintended effects of these conditions.
TL;DR: Possible vertical transmission of SARS CoV-2 has been observed in some studies currently and more RT-PCR tests on amniotic fluid, placenta, breast milk and cord blood are required.
Abstract: The aim of this study is to review the current evidence on the vertical transmission of SARS CoV-2. Combination of the following keywords; COVID-19, SARS CoV-2, placenta, vertical transmission, int...
TL;DR: The performance of the fetal fibronectin test was also too low to be clinically relevant, and the best use policy probably still depends on local contingencies, future cost-effectiveness analysis, and comparison with other more recent available biochemical markers.
Abstract: Background: The identification of women at risk for preterm birth should allow interventions which could improve neonatal outcome. Fetal fibronectin, a glycoprotein which acts normally as g...
TL;DR: Children born after ART were at an increased risk of birth defects compared with NC, and both IVF and ICSI increase the risk ofBirth defects.
Abstract: Background: Assisted reproductive technologies (ARTs) have made great progress. However, whether tube baby born after ART were at an increased risk of birth defects is not clear.Objective: To assess whether the ART increases the risk of birth defects in children born after ART.Search strategy: Medline, Google Scholar, and the Cochrane Library were searched.Selection criteria: Clinical trials that evaluate the risk of birth defect in children born after in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) and natural conceptions (NC) were included. The primary outcome was the prevalence of birth defects.Data collection and analysis: The relative risk was used as the summary measure with random effects model. We assessed heterogeneity between studies using the I2 index.Main results: Totally 46 studies were included. The pooled relative risk (RR) estimated suggested there was an increased risk of birth defects in ART compared with the NC group (RR: 1.40; 95% CI 1.31-1.49). Twenty and fifteen studies were included to compare the risk of birth defects between NC and IVF/ICSI, respectively. The results indicated that both IVF and ICSI increase the risk of birth defects (IVF: RR 1.25; 95% CI 1.12-1.40; ICSI: RR 1.29; 95% CI 1.14-1.45). When subgroup according to plurality, 22 studies assessed the risk of birth defects after ART or NC in singletons and 15 studies evaluated the risk of birth defects in twins. The pooled RRs were 1.41 (95% CI 1.30-1.52) and 1.18 (95% CI 0.98-1.42), respectively.Conclusions: Children born after ART were at an increased risk of birth defects compared with NC. There was no difference in birth defects risk between ART twins and NC twins.
TL;DR: Rheumatoid arthritis in pregnancy is associated with a greater likelihood of adverse maternal and neonatal outcomes and women with RA should be made aware of these risks and be followed as a high risk pregnancy.
Abstract: Purpose: To assess if pregnancies in women with rheumatoid arthritis (RA) are at a higher risk for adverse maternal and neonatal outcomes.Materials and methods: A retrospective cohort study was carried out using the Healthcare Cost and Utilization Project - National Inpatient Sample (HCUP-NIS) from the USA. All births that took place from 2004 to 2013 were identified and women were classified as having RA or not on the basis of ICD-9 coding. Unconditional logistic regression was used to evaluate the adjusted effect of RA on maternal and neonatal outcomes.Results: Of the total 8,417,607 births in our cohort, 6068 were among women with RA for an overall prevalence of 72 per 100,000 births. There was a steady increase in reported RA in pregnancy from 47 to 100 per 100,000 over the 10-year study period. Compared with women without RA, women with RA were more likely to develop pre-eclampsia/eclampsia, gestational diabetes, to present with preterm premature rupture of membranes(PPROM), to experience placental abruption and placenta previa, and to deliver by caesarean section. Postpartum, RA-complicated pregnancies were associated with wound complications and thromboembolisms. Congenital anomalies, small for gestational age and preterm birth were more common in neonates of women with RA.Conclusion: RA in pregnancy is associated with a greater likelihood of adverse maternal and neonatal outcomes. Women with RA should be made aware of these risks and be followed as a high risk pregnancy.
TL;DR: The worse mother-infant bonding was suspected at 1 month after birth under the COVID-19 pandemic, based on the results of mental screening of the postpartum women conducted during the CO VID-19 epidemic.
Abstract: Under the COVID-19 (Coronavirus Disease 2019) pandemic, limitations are known to cause some psychosocial problems. We compared the results of mental screening of the postpartum women conducted during the COVID-19 epidemic with those at the same period last year. Based on the results, the worse mother-infant bonding was suspected at 1 month after birth under the COVID-19 pandemic.
TL;DR: It is suggested that maternal mortality mostly happened among women with previous co-morbidities and neonatal mortality seems to be a result of prematurity rather than infection, however, the magnitude of the maternal and perinatal mortality could be determined more precisely.
Abstract: This is the first comprehensive review to focus on currently available evidence regarding maternal, fetal and neonatal mortality cases associated with Coronavirus Disease 2019 (COVID-19) infection,...
TL;DR: These data support the concept that different pathophysiologic mechanisms are implicated in early- and late-onset preeclampsia, and provide insight into the ELABELA axis during the human syndrome of preeClampsia.
Abstract: Objective: ELABELA is a newly discovered peptide hormone that appears to be implicated in the mechanisms leading to preeclampsia, independently of angiogenic factors. The aim of the current study w...
TL;DR: A literature review on the putative effectiveness and safety of available treatments for COVID-19 in pregnant women and whose safe assumption during pregnancy had been demonstrated by clinical studies is provided.
Abstract: Background: COVID-19 is a pandemic disease caused by the SARS-CoV-2 and it spread globally in the last few months. The complete lack of specific treatment forced clinicians to use old drugs, chosen for their efficacy against similar viruses or their in vitro activity. Trials on patients are ongoing but the majority of information comes from small case series and single center reports. We aimed to provide a literature review on the putative effectiveness and safety of available treatments for COVID-19 in pregnant women.Methods: We reviewed all the available literature concerning the drugs that have been used in the treatment of COVID-19 during pregnancy and whose safe assumption during pregnancy had been demonstrated by clinical studies (i.e. including studies on other infectious diseases). Drugs contra-indicated during pregnancy or with unknown adverse effects were not included in our review.Results and conclusions: Clinical trials are not often conducted among pregnant patients for safety reasons and this means that drugs that may be effective in general population cannot be used for pregnant women due to the lack of knowledge of side effects in this category of people .The choice to use a specific drug for COVID-19 in pregnancy should take into account benefits and possible adverse events in each single case. In the current situation of uncertainty and poor knowledge about the management of COVID-19 during pregnancy, this present overview may provide useful information for physicians with practical implications.
TL;DR: The information compiled in this systematic review may help healthcare providers administer the best possible care in pregnancy by evaluating the impact of COVID-19 during pregnancy.
Abstract: There is limited information related to COVID-19 in pregnancy. Evaluate the impact of COVID-19 during pregnancy. Search strategy: Searches were systematically carried out in PubMed, Scopus database...
TL;DR: In this paper, the placenta transports, utilizes, produces, and interconverts amino acids (AAs), and concentrations of both nonessential and essential AAs in maternal plasma decrease in early pregnancy and persist at low concentrations throughout.
Abstract: Background: Pregnancy is characterized by a complexity of metabolic processes that may impact fetal development and infant health outcome. Normal fetal growth and development depend on a continuous supply of nutrients via the placenta. The placenta transports, utilizes, produces, and interconverts amino acids (AAs).Findings: Concentrations of both nonessential and essential AAs in maternal plasma decrease in early pregnancy and persist at low concentrations throughout. The decline is greatest for the glucogenic AAs and AAs of the urea cycle. Additionally, there is a large placental utilization of the branched-chain AAs, some of which are transaminated to alpha ketoacids and contribute to placental ammonia production. Both nonessential and essential AAs regulate key metabolic pathways to improve health, survival, growth, development, lactation, and reproduction of organisms. Some of the nonessential AAs (e.g. glutamine, glutamate, and arginine) play also important roles in regulating gene expression, cell signaling, antioxidant responses, immunity, and neurological function.Conclusions: Nutritional support during pregnancy is of great interest focusing not only to common pregnancies but also to those with low socioeconomic status, vegan-vegetarian groups, and pregnant women with metabolic disorders, the most known maternal phenylketonuria. The latter is of great interest because phenylalanine must be within the recommended range throughout pregnancy in addition to other nutrients such as vitamin B12, folate, etc. Loss of the adherence to this specific diet results in congenital malformations of the fetus. In addition to the routine laboratory test, quantitation of plasma AAs may be necessary throughout pregnancy.
TL;DR: These cases have notable variation in the epidemiology, clinical features, results of testing and clinical outcomes among the infected newborns.
Abstract: There have been few cohorts of neonates with coronavirus disease-2019 (COVID-19) reported. As a result, there remains much to be learned about mechanisms of neonatal infection including potential v...
TL;DR: The results of this cohort reveal that SARSC-CoV-2 infection may not behave as mild as suggested during pregnancy, especially when factors as obesity or Latin-American origin are present.
Abstract: There is little evidence about how novel coronavirus (SARS-CoV-2) affects pregnant women and their newborns. Comparisons with other members of the coronavirus family responsible for severe acute re...
TL;DR: Near miss cases of PAS are commonly associated with posterior bladder or parametrial invasion and placenta percreta, and invasion in the inferior part of the lower uterine segment, posterior bladder and parametria was associated with high risk of morbidity.
Abstract: Purpose of the article: Placental accreta spectrum (PAS) is the most dangerous iatrogenic complication of cesarean potentially leading to massive intra-partum haemorrhage and death. Despite this, i...
TL;DR: The findings suggest that the slower growth of twins may reflect a state of “relative growth restriction” compared with singleton gestations.
Abstract: Objective: Twin fetus growth is delayed during the third trimester compared to singletons. Whether this phenomenon should be considered a normal physiologic characteristic of twins or a pathologic ...
TL;DR: In the study group, preterm infants from 28 to 34 weeks of GA, NHFOV did not reduce the need for mechanical ventilation during the first 72 h after birth compared to NCPAP; however, the duration of noninvasive ventilation in theNHFOV group was significantly shorter.
Abstract: Background: Respiratory distress syndrome (RDS) is one of the main causes of mortality in premature neonates. Treatment of these neonates with invasive mechanical ventilation has side effects such ...
TL;DR: The four studied sleep disturbances (OSA, snoring, extreme sleep duration and poor sleep quality) during pregnancy were associated with adverse perinatal outcomes and expectant mothers should be advised to practice healthy sleep hygiene measures.
Abstract: Background: Due to physiological and hormonal factors, sleep disturbances are prevalent in the obstetric population. Multiple studies have evaluated the relationship between sleep disturbances and perinatal outcomes, with inconsistent results. The purpose of this systematic review and meta-analysis was to further assess the overall relationship between four types of sleep disturbances (snoring, obstructive sleep apnea, extreme sleep duration, and poor sleep quality) and adverse perinatal outcomes.Methods: We performed electronic searches in PubMed, Embase, the Cochrane Library, CNKI, VIP, and Wanfang Data in February 2019 to identify studies that assessed adverse perinatal outcomes among expectant mothers with sleep disturbances.Results: In total, 5044 studies were identified in the initial search and 65 met the defined criteria. Pooled analysis showed that sleep disturbances were associated with an increased risk for preeclampsia (aOR: 2.77; 95% CI: 1.81-4.24), gestational diabetes mellitus (aOR: 1.96; 95% CI: 1.62-2.38), cesarean delivery (aOR: 1.99; 95% CI: 1.70-2.33), depression (aOR: 3.98; 95% CI: 2.74-5.77) and preterm birth (aOR: 1.95; 95% CI: 1.55-2.45).Conclusions: The four studied sleep disturbances (OSA, snoring, extreme sleep duration and poor sleep quality) during pregnancy were associated with adverse perinatal outcomes. Expectant mothers should be advised to practice healthy sleep hygiene measures.
TL;DR: In women with established PPH after vaginal delivery, the use of TXA reduces therisk of hysterectomy and does not increase the risk of thrombotic events.
Abstract: Background: Postpartum hemorrhage (PPH) is responsible for about 25% of maternal deaths worldwide. Antifibrinolytic agents, mainly tranexamic acid (TXA), have been demonstrated to reduce bl...