Tranexamic acid for childbirth: why, when, and for whom

ABSTRACT

Introduction: Postpartum hemorrhage (PPH) is a major cause of maternal death and severe maternal morbidity after childbirth.

Areas covered: Tranexamic acid, an antifibrinolytic agent, reduces bleeding-related mortality in women with PPH, especially when administered shortly after delivery, and is consequently recommended in this situation (1g intravenously with a second dose of 1 g if bleeding continues), even in high income countries where the magnitude of the effect of tranexamic is uncertain.

Expert opinion: Pharmacovigilance surveys are warranted in high income areas to ensure that this new policy for the treatment of PPH is not associated to rare but severe adverse events such as renal failure. The evidence remains insufficient to recommend the universal use of tranexamic acid for prevention of postpartum hemorrhage after both vaginal and cesarean deliveries.

KEYWORDS:

• Postpartum hemorrhage
• prevention
• treatment
• guidelines
• tranexamic acid
• transfusion
• blood loss
• hysterectomy
• cesarean delivery
• vaginal delivery

Article highlights

• Postpartum hemorrhage is one of the leading causes of maternal death and severe maternal morbidity worldwide.

• Because individual risk factors are poor predictors of postpartum hemorrhage, its prevention should be directed to all women giving birth.

• Tranexamic acid should be administered to all women with PPH 1g intravenously, as early as possible for the treatment of established postpartum hemorrhage (especially if there is no initial response to uterotonics), with a second dose of 1 g IV if bleeding continues after 30 minutes.

• As the generalizability of the WOMAN trial’s results and the expected effect in high-income countries are uncertain, pharmacovigilance surveys are warranted in these settings to ensure that this new policy for the treatment of PPH is not associated to rare but severe adverse events such as acute renal cortical necrosis in hemorrhagic women.

• The evidence remains insufficient to recommend the use of tranexamic acid as routine prophylaxis against postpartum hemorrhage after both vaginal and cesarean deliveries worldwide.

• Nevertheless, the benefit/harm ratio of prophylactic tranexamic acid, an inexpensive and heat drug that does not require cold chain transport and storage, at a fixed dose of 1g intravenously after vaginal delivery is debatable in some low-income areas with low availability of adequate equipment and resources for PPH treatment.

Declaration of interest

L Sentilhes was a board member and carried out consultancy work and lecturer for Ferring. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or conflict with the subject matter or materials discussed in this manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.