What is the treatment for a woman with uterine bleeding using Tranexamic Acid (TXA)?

Tranexamic Acid for Uterine Bleeding

Tranexamic acid (TXA) is indicated specifically for postpartum hemorrhage (PPH) following vaginal birth or cesarean section, administered as 1 g IV over 10 minutes within 3 hours of birth, but is NOT recommended for other types of uterine bleeding including miscarriage, dysfunctional uterine bleeding during pregnancy, or first/second trimester bleeding. 1, 2

Critical Distinction: When TXA Is and Is NOT Indicated

Approved Indication: Postpartum Hemorrhage Only

• The WHO strongly recommends TXA for clinically diagnosed PPH (>500 mL blood loss after vaginal birth or >1000 mL after cesarean section) following delivery of a viable infant 2
• TXA reduces death from bleeding by 31% when given within 3 hours of birth (RR 0.69,95% CI 0.52-0.91) 3
• Time-critical administration: Efficacy decreases by approximately 10% for every 15-minute delay, with no benefit and potential harm after 3 hours post-birth 2, 4

Contraindicated or Not Recommended Scenarios

• Intrauterine miscarriage: The WHO explicitly states TXA is NOT recommended for intrauterine miscarriage, and there is no evidence supporting its use in first or second trimester miscarriage, incomplete abortion, or bleeding from retained products of conception 1
• Pre-delivery bleeding: No evidence exists for TXA use in any pregnancy loss before viable delivery 1
• Active thromboembolic disease: Absolute contraindication in patients with active intravascular clotting or history of thromboembolic events during pregnancy 5

Dosing Protocol for Postpartum Hemorrhage

Standard Regimen

• First dose: 1 g IV administered over 10 minutes (at 1 mL/min) as soon as PPH is diagnosed 2, 5
• Second dose: Additional 1 g if bleeding continues after 30 minutes OR restarts within 24 hours of first dose 2, 4
• Route: Intravenous only—not intramuscular 5

Administration Timing Algorithm

1. 0-3 hours post-birth: Administer immediately—maximum benefit window 2, 3
2. >3 hours post-birth: Do NOT administer—may be harmful with no demonstrated benefit 1, 2

Mechanism and Efficacy

• TXA reduces bleeding by inhibiting fibrinolysis (breakdown of blood clots) 4
• In the landmark WOMAN trial (20,060 women), TXA reduced death due to bleeding from 1.9% to 1.5% (RR 0.81,95% CI 0.65-1.00) with no increase in thromboembolic events 3
• TXA should be given alongside standard PPH management including uterotonics (oxytocin 5-10 IU), fluid resuscitation, and uterine massage 2

Safety Profile

• No significant increase in thromboembolic events in PPH patients 3, 6
• Exception: Evidence suggests increased venous thrombosis risk in gastrointestinal bleeding contexts, though this does not apply to PPH 6
• Adverse effects are generally mild and infrequent 7
• Higher doses (not standard PPH dosing) associated with increased seizure risk 6

Alternative Context: Heavy Menstrual Bleeding (Non-Pregnant)

• For non-pregnant women with heavy menstrual bleeding (menorrhagia), TXA reduces menstrual blood loss by 26-60% 7
• Dosing for menorrhagia: 3.9-4 g/day orally for 4-5 days starting from first day of menstrual cycle 7
• This is a completely separate indication from pregnancy-related bleeding 7, 8

Common Pitfalls to Avoid

• Do not use TXA for miscarriage bleeding: Despite being effective for PPH, there is zero evidence for pregnancy loss scenarios and WHO explicitly recommends against it 1
• Do not delay administration: Every 15 minutes of delay reduces efficacy by 10% in PPH 2, 4
• Do not give beyond 3-hour window: Late administration may cause harm without benefit 1, 2
• Do not confuse with menorrhagia dosing: PPH uses IV fixed-dose regimen (1 g), while menorrhagia uses higher oral daily doses (3.9-4 g/day) 2, 7