Can tranexamic acid (TXA) be given during pregnancy?

Use of Tranexamic Acid During Pregnancy

Tranexamic acid (TXA) can be safely administered during pregnancy when clinically indicated, particularly for the treatment of postpartum hemorrhage, with appropriate consideration of contraindications. 1, 2

Indications for TXA During Pregnancy

• TXA is recommended for the treatment of postpartum hemorrhage (PPH) and should be administered as soon as possible, within 3 hours of birth, for maximum effectiveness 1
• In women with congenital fibrinogen disorders who have a bleeding phenotype, TXA is suggested for prophylaxis at the time of delivery 1
• TXA may be considered for prevention of secondary PPH and management of prolonged or heavy lochia, depending on thrombotic risk 1
• For pregnancy loss management in women with afibrinogenemia and severe hypofibrinogenemia, TXA is recommended for 3 days along with fibrinogen replacement targeting levels ≥1.5 g/L 1

Dosing and Administration

• For PPH treatment, the recommended dose is 1g IV administered over 10 minutes, with a possible second dose if bleeding continues after 30 minutes or restarts within 24 hours 1, 3
• Efficacy decreases by approximately 10% for every 15-minute delay in administration, with no benefit seen after 3 hours post-birth 1
• For prevention of PPH, studies have explored various dosing regimens including 5-15 mg/kg (maximum 1000 mg), with 600 mg proposed as an optimal prophylactic dose 3

Safety Considerations

Contraindications and Precautions

• TXA should be avoided in women with clear contraindications to antifibrinolytic therapy, such as known thromboembolic events during pregnancy 1, 2
• Concomitant use with hormonal contraceptives may increase the risk for thromboembolic adverse reactions 2
• TXA crosses the placenta with cord blood concentrations approximately equal to maternal concentrations 2

Adverse Effects

• Common adverse effects include gastrointestinal disturbances (nausea, vomiting, diarrhea) which may resolve with dose reduction 2
• Rare but serious adverse events include thromboembolic events (deep vein thrombosis, pulmonary embolism, cerebral thrombosis) 2
• Hypotension may occur with rapid IV administration 2

Special Considerations

Breastfeeding

• TXA is present in human milk but at concentrations approximately 1% or less of maternal plasma levels 2, 3
• The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for TXA 2

Pregnancy Loss Management

• For surgical management after pregnancy loss in women with afibrinogenemia and severe hypofibrinogenemia, TXA is recommended for 3 days 1
• For mild and moderate hypofibrinogenemia without bleeding history, spontaneous expulsion can be considered with TXA administration 1

Evidence Quality and Gaps

• While evidence supports TXA use for PPH treatment, data on prophylactic use is still evolving 4, 5
• A meta-analysis of three randomized controlled trials showed a trend toward reduced blood loss with TXA during cesarean sections (32.5 ml reduction, 95% CI -4.1-69.13; p = 0.08) 6
• The TRAAP trial found that prophylactic TXA did not significantly reduce PPH ≥500 ml after vaginal delivery compared to placebo, though it did reduce provider-assessed clinically significant PPH 7

Clinical Decision Algorithm

1. Assess indication: Is this for PPH treatment, prophylaxis in high-risk patients, or management of pregnancy loss?
2. Check for contraindications: History of thromboembolic events or other clear contraindications to antifibrinolytic therapy
3. Consider timing: For PPH treatment, administer within 3 hours of birth, preferably as soon as possible
4. Select appropriate dose based on indication
5. Monitor for adverse effects, particularly signs of thromboembolism