What is the dose of tranexamic acid (TXA) used to stop postpartum hemorrhage (PPH) in a pregnant woman during labor?

From the Guidelines

The recommended dose of tranexamic acid for postpartum hemorrhage is 1 gram (1000 mg) given intravenously over 10 minutes, as supported by the most recent and highest quality study 1. This dose should be administered as soon as possible after the onset of bleeding, ideally within 3 hours, as its effectiveness decreases with delay. If bleeding continues after 30 minutes, a second dose of 1 gram can be administered, as indicated by previous studies 1. Tranexamic acid works by inhibiting fibrinolysis, promoting clot stability, and reducing blood loss. For maximum effectiveness, it should be administered alongside other standard treatments for postpartum hemorrhage, such as uterotonic medications, uterine massage, and fluid resuscitation. Healthcare providers should be aware of the potential contraindications and side effects, including a history of thromboembolism and renal impairment, as well as nausea, vomiting, and hypotension if administered too rapidly. Key points to consider when administering tranexamic acid include:

• Timing: administer as soon as possible after bleeding onset, ideally within 3 hours
• Dose: 1 gram (1000 mg) intravenously over 10 minutes
• Potential for a second dose: if bleeding continues after 30 minutes
• Importance of concurrent standard treatments: uterotonic medications, uterine massage, and fluid resuscitation
• Awareness of contraindications and side effects: history of thromboembolism, renal impairment, nausea, vomiting, and hypotension.

From the Research

Dose of Tranexamic Acid for Bleeding in Pregnant Women

• The optimal dose of tranexamic acid to prevent postpartum hemorrhage is proposed to be 600 mg, based on a study that found this dose to be effective in preventing blood loss after cesarean delivery 2.
• A meta-analysis of randomized controlled trials found that prophylactic use of tranexamic acid 1 g IV within 10 minutes after vaginal delivery reduces the risk of primary postpartum hemorrhage 3.
• Another study found that tranexamic acid plasma concentration of >10 μg/mL and maximum lysis of <17% were achieved with doses of 5,10, or 15 mg/kg (maximum, 1000 mg) of intravenous tranexamic acid at umbilical cord clamping 2.
• The World Health Organization recommends that tranexamic acid be part of the standard comprehensive postpartum hemorrhage treatment package, and US professional organizations recognize its use as adjunctive treatment for postpartum hemorrhage 4.
• An umbrella review of systematic reviews of randomized trials found that tranexamic acid can reduce blood loss and hemorrhage in gynecology and obstetrics procedures, including cesarean section, myomectomy, hysterectomy, and cervical intraepithelial neoplasia surgery 5.

Administration and Timing

• Early administration of tranexamic acid is important for efficacy, particularly in trauma and postpartum hemorrhage 6.
• Tranexamic acid should be administered at umbilical cord clamping, with a dose of 5,10, or 15 mg/kg (maximum, 1000 mg) of intravenous tranexamic acid 2.
• Prophylactic use of tranexamic acid 1 g IV within 10 minutes after vaginal delivery reduces the risk of primary postpartum hemorrhage 3.

Safety and Efficacy

• There is no evidence that tranexamic acid increases the risk of thrombotic events in patients with major bleeding overall, but there is evidence of increased risk of venous thrombosis in patients with gastrointestinal bleeding 6.
• Tranexamic acid is safe and effective in reducing blood loss and hemorrhage in gynecology and obstetrics procedures, including cesarean section, myomectomy, hysterectomy, and cervical intraepithelial neoplasia surgery 5.
• The quality of systematic reviews on the efficacy of tranexamic acid in gynecology and obstetrics procedures is low or critically low, and the quality of evidence is moderate 5.