What medication is recommended to stop bleeding during the first trimester of pregnancy?

Management of Bleeding During First Trimester of Pregnancy

Tranexamic acid is the recommended medication to stop bleeding during the first trimester of pregnancy, administered at a dose of 1g intravenously, with a potential second dose if bleeding continues after 30 minutes or restarts within 24 hours. 1, 2

First-Line Treatment for First Trimester Bleeding

• Tranexamic acid (TXA) is effective in accelerating hemostasis in the uteroplacental circulation and reducing adverse effects of bleeding at the placental site 3
• The recommended dosing regimen is:
  • Initial dose: 1g intravenously (100 mg/mL) administered over 10 minutes
  • Second dose: 1g intravenously if bleeding continues after 30 minutes or restarts within 24 hours 1, 2

Mechanism and Evidence

• Tranexamic acid works by inhibiting the breakdown of blood clots, helping to maintain clot stability and reduce bleeding 2
• Studies have shown that tranexamic acid treatment in women with vaginal bleeding during pregnancy can:
  • Decrease plasma fibrinolytic activity
  • Reduce plasminogen and antiplasmin levels
  • Increase antithrombin III and factor VIII related antigen 3
• Meta-analysis of randomized controlled trials has shown that tranexamic acid reduces blood loss during cesarean sections and vaginal deliveries 4

Safety Considerations

• Tranexamic acid is generally considered safe during pregnancy when used appropriately 3, 4
• Plasma tranexamic acid levels detected in umbilical cord blood have been reported at 9-12 mg/L when mothers received treatment 3
• Timing is critical - evidence suggests that tranexamic acid is most effective when given early after bleeding onset 2
• Monitor for potential adverse effects:
  • Thromboembolic events (though rare, cases of pulmonary embolism have been reported) 4
  • Renal function should be monitored, especially in high-risk patients 5

Special Considerations for Anticoagulated Patients

• For pregnant patients already on anticoagulation therapy who develop bleeding:
  • Low-molecular-weight heparin (LMWH) is the preferred anticoagulant during pregnancy if anticoagulation must be continued 1
  • Temporary reduction or cessation of anticoagulation may be necessary to control bleeding, with careful risk-benefit assessment 1, 6
  • Vitamin K antagonists should be avoided during pregnancy, especially during the first trimester, due to risk of embryopathy 1

Follow-up and Monitoring

• After initial treatment with tranexamic acid, patients should be monitored for:
  • Resolution of bleeding
  • Hemodynamic stability
  • Signs of continued blood loss 1, 2
• Ultrasound evaluation may be necessary to assess fetal viability and identify potential causes of bleeding (e.g., subchorionic hematoma) 3

Common Pitfalls to Avoid

• Delaying treatment - tranexamic acid should be administered as soon as possible after bleeding onset 2
• Using tranexamic acid beyond 3 hours after bleeding onset, as evidence suggests diminished benefit 1, 2
• Failure to monitor for potential thromboembolic complications, especially in patients with risk factors 4
• Inadequate dosing - follow the recommended dosing regimen of 1g IV with potential second dose 1, 2