From the Guidelines
Tranexamic acid is the best medication for postpartum hemorrhage prophylaxis besides oxytocin or methergine, given its ability to reduce morbidity and mortality associated with postpartum bleeding. According to the WHO recommendation updated in 2018 1, tranexamic acid should be administered intravenously at a fixed dose of 1 g (100 mg/mL) over 10 minutes, with a second dose of 1 g intravenously if bleeding continues after 30 minutes, or if bleeding restarts within 24 hours of completing the first dose. This recommendation is based on the dosing regimen used in the WOMAN trial, which demonstrated the efficacy of tranexamic acid in reducing mortality due to postpartum hemorrhage. Key points to consider when using tranexamic acid for postpartum hemorrhage prophylaxis include:
- Administration within 3 hours of birth for maximum benefit
- Use in addition to standard care for women with clinically diagnosed postpartum hemorrhage
- Clinically diagnosed postpartum hemorrhage refers to a clinically estimated blood loss of more than 500 mL after vaginal birth or 1000 mL after caesarean section
- Tranexamic acid should be given in all cases of postpartum hemorrhage, regardless of the cause of bleeding, as stated in the updated WHO recommendation 1.
From the Research
Alternative Medications for Postpartum Hemorrhage Prophylaxis
Besides oxytocin or methergine, several other medications can be used for postpartum hemorrhage prophylaxis, including:
- Carbetocin: a long-acting analog of oxytocin, which is likely the most effective single pharmacologic therapy for prevention of postpartum hemorrhage 2
- Misoprostol: a prostaglandin analog that can be used in combination with oxytocin for additive or synergistic effect 2
- Ergometrine: a uterotonic agent that can be used in combination with oxytocin for additive or synergistic effect 2, 3
- Tranexamic acid: an antifibrinolytic agent that can be used to decrease maternal mortality in women with postpartum hemorrhage 2
- Carboprost: a prostaglandin analog that can be used as a second-line uterotonic agent 3
Combination Therapies
Combination therapies, such as oxytocin and misoprostol or oxytocin and ergometrine, can be more effective than single-agent therapies in preventing postpartum hemorrhage 2, 3. However, the optimal combination and dosing regimen is still unclear and requires further study.
Network Meta-Analysis
A network meta-analysis of available pharmacologic agents for preventing postpartum hemorrhage after cesarean delivery found that carbetocin was probably the most effective agent in reducing blood loss and the need for additional uterotonics 3. Oxytocin was found to be more effective when initiated as a bolus.
Guidelines and Recommendations
Various guidelines and recommendations for the prevention and management of postpartum hemorrhage emphasize the importance of active management of the third stage of labor, including the administration of oxytocin as the criterion standard 4, 5. However, there is some variation in the recommended regimens and protocols for uterotonics and other interventions.