What is the appropriate administration of Tranexa (tranexamic acid) 500 mg/5 mL intravenous (IV) injection for a female patient presenting with bleeding per vagina?

Administration of Tranexamic Acid for Vaginal Bleeding

Administer tranexamic acid 1g (10 mL of the 100 mg/mL solution) intravenously over 10 minutes immediately upon diagnosis of clinically significant vaginal bleeding, with a second 1g dose if bleeding continues after 30 minutes or restarts within 24 hours. 1, 2

Critical Timing Requirements

• The 3-hour window is absolute: Tranexamic acid must be administered within 3 hours of bleeding onset to achieve maximum efficacy 1
• Efficacy decreases by 10% for every 15-minute delay in administration 1, 2
• Administration after 3 hours may paradoxically increase the risk of death from bleeding and should be avoided 1

Standard IV Administration Protocol

Dosing and Rate

• Draw up 10 mL from the vial (1000 mg total) for IV administration 3
• Infuse at no more than 1 mL/minute (total infusion time: 10 minutes minimum) to avoid hypotension 3
• A second dose of 1g IV should be given if bleeding continues after 30 minutes or if bleeding restarts within 24 hours of the first dose 1, 2

Preparation and Compatibility

• Inspect the solution visually for particulate matter and discoloration before administration 3
• May be mixed with electrolyte solutions, carbohydrate solutions, amino acid solutions, or Dextran solutions if dilution is needed 3
• Do NOT mix with blood products or penicillin-containing solutions 3
• Heparin may be added to tranexamic acid if needed 3

Clinical Context Assessment

When Tranexamic Acid IS Indicated for Vaginal Bleeding:

• Postpartum hemorrhage (blood loss >500 mL after vaginal delivery or any bleeding compromising hemodynamic stability) - regardless of whether due to uterine atony or genital tract trauma 1, 2
• Significant dysfunctional uterine bleeding in non-pregnant patients with hemodynamic compromise 2
• Any vaginal bleeding sufficient to cause hemodynamic instability 1

When Tranexamic Acid is NOT Indicated:

• First or second trimester miscarriage/incomplete abortion - there is no evidence supporting use in pregnancy loss before viable delivery 4
• Bleeding from retained products of conception in early pregnancy 4
• Routine menorrhagia without hemodynamic compromise (oral formulation preferred in this setting) 5

Renal Function Considerations

Check serum creatinine before administration when possible, as dose adjustment is required for renal impairment 3:

• Creatinine 1.36-2.83 mg/dL: Reduce to 10 mg/kg twice daily 3
• Creatinine 2.83-5.66 mg/dL: Reduce to 10 mg/kg once daily 3
• Creatinine >5.66 mg/dL: Reduce to 10 mg/kg every 48 hours or 5 mg/kg every 24 hours 3

Absolute Contraindications

• Active intravascular clotting or disseminated intravascular coagulation 3
• Known hypersensitivity to tranexamic acid 3
• Subarachnoid hemorrhage (risk of cerebral edema and infarction) 3

Critical Safety Warnings

Route Verification

• Confirm intravenous route only - intrathecal administration has caused seizures and cardiac arrhythmias 3
• Label syringes clearly with "IV ONLY" to prevent route confusion 3

Thrombotic Risk Management

• Use with extreme caution in patients on oral contraceptives (increased thrombosis risk) 6
• Avoid concomitant use with pro-thrombotic agents (Factor IX concentrates, anti-inhibitor coagulant concentrates) 3
• Despite theoretical concerns, large meta-analyses show no increased thromboembolic risk at standard doses in appropriate bleeding scenarios 6

Seizure Risk

• Seizures can occur, particularly at doses higher than recommended (>1g per dose) 3
• Monitor neurological status during and after administration 3

Common Clinical Pitfalls to Avoid

• Do not delay administration waiting for laboratory results or imaging if clinical diagnosis of significant bleeding is clear 1
• Do not use topical/vaginal administration for systemic bleeding - IV route achieves therapeutic plasma levels necessary for systemic fibrinolysis inhibition 6
• Do not give after the 3-hour window - this may cause harm rather than benefit 1
• Do not confuse with prevention protocols - the evidence for prophylactic use differs from treatment of established bleeding 7