From the Guidelines
Tranexamic acid (TXA) should not be administered routinely in patients with good uterine tone, as its use is primarily indicated for hemorrhage with hyperfibrinolysis or coagulopathy. In postpartum hemorrhage, the first-line treatment should address the underlying cause, which is most commonly uterine atony. If the uterus has good tone, other causes of bleeding such as lacerations, retained placental tissue, or coagulation disorders should be investigated and treated specifically. Some key points to consider:
- The World Health Organization (WHO) recommends early use of intravenous tranexamic acid for the treatment of post-partum haemorrhage, but this is in the context of clinically diagnosed post-partum haemorrhage with significant blood loss or hemodynamic instability 1.
- The WOMAN trial demonstrated the effectiveness of tranexamic acid in reducing mortality in women with post-partum haemorrhage, but this was in a population with significant bleeding 1.
- If bleeding persists despite good uterine tone and no other obvious cause is found, TXA could be considered as part of the management at a dose of 1 gram IV over 10 minutes, with a second dose if bleeding continues after 30 minutes, as supported by the WHO recommendation 1.
- TXA works by inhibiting plasminogen activation, thereby preventing fibrin degradation and stabilizing clots, but its use should be judicious and based on clinical assessment rather than routine administration when uterine tone is adequate and no significant bleeding is present.
- Unnecessary administration of TXA carries risks including thrombotic events, particularly in patients with predisposing factors, as highlighted in various studies including the CRASH-2 trial collaborators 1.
From the Research
Administration of Tranexamic Acid (TXA) in Patients with Good Uterine Tone
- The use of tranexamic acid (TXA) in patients with good uterine tone is a topic of interest in the prevention of postpartum hemorrhage (PPH) 2, 3, 4, 5, 6.
- Studies have shown that TXA can reduce the risk of life-threatening postpartum bleeding, with a pooled odds ratio of 0.77 (95% CI 0.63-0.93) 4.
- The World Health Organization recommends TXA as part of the standard comprehensive PPH treatment package, and US professional organizations recognize its use as adjunctive treatment for PPH 3.
- Evidence suggests that prophylactic use of TXA in women at high risk of PPH may decrease blood loss and the incidence of PPH 3, 6.
- However, the optimal dose of TXA for PPH prevention is still being studied, with a proposed dose of 600 mg in future efficacy studies 6.
- The decision to administer TXA in a patient with good uterine tone should be based on individual risk factors and clinical judgment, taking into account the potential benefits and risks of TXA use 2, 3, 4, 5, 6.
- Key considerations include the patient's underlying risk of life-threatening bleeding, type of birth, presence of moderate or severe anemia, and timing of administration 4.