From the Guidelines
Tranexamic acid (TXA) should not be given after every vaginal birth, but rather reserved for cases with postpartum hemorrhage or high risk of bleeding, as evidenced by the World Health Organization's (WHO) updated recommendation 1. The standard dose of TXA for postpartum hemorrhage is 1 gram IV given over 10 minutes, with a second dose of 1 gram if bleeding continues after 30 minutes or recurs within 24 hours of the first dose 1. TXA works by inhibiting fibrinolysis, helping to stabilize blood clots and reduce bleeding.
The WHO's updated recommendation emphasizes the importance of early treatment with TXA, ideally within 3 hours of birth, to reduce maternal death due to bleeding in women with clinically diagnosed postpartum hemorrhage 1. The WOMAN trial, a randomized, double-blind, placebo-controlled trial, demonstrated that early use of intravenous TXA reduces maternal death due to bleeding in women with postpartum hemorrhage 1.
Key points to consider when using TXA for postpartum hemorrhage include:
- The 3-hour threshold after birth, beyond which TXA should not be given 1
- The importance of early treatment to maximize benefits 1
- The potential harms of delayed treatment, which may reduce benefit or even be harmful 1
- The need to identify patients at higher risk for postpartum hemorrhage and consider TXA use in those specific situations 1
Overall, while TXA has been shown to reduce mortality in women with postpartum hemorrhage, routine prophylactic use for all vaginal deliveries has not demonstrated sufficient benefit to justify universal administration 1. Healthcare providers should focus on identifying patients at higher risk for postpartum hemorrhage and consider TXA use in those specific situations rather than as a standard practice for all vaginal births.
From the Research
Tranexamic Acid Administration After Vaginal Birth
- The use of tranexamic acid (TXA) after vaginal birth to prevent postpartum hemorrhage (PPH) has been studied in several trials 2, 3, 4, 5, 6.
- A Cochrane review found that prophylactic TXA in addition to standard care compared to placebo in addition to standard care results in little to no difference in blood loss ≥ 500 mL and likely makes little to no difference to blood loss ≥ 1000 mL or the risk of severe morbidity 2.
- Another study found that TXA used prophylactically in the setting of cesarean birth may decrease blood loss and the incidence of PPH, but there is limited evidence for prophylactic use in women of all risk categories following vaginal birth 3.
- A review of trials found that TXA decreases postpartum blood loss and prevents PPH and blood transfusions following vaginal birth and CS in women at low risk of PPH, but there is insufficient evidence to draw conclusions about serious side effects 4.
- A retrospective study found that TXA administration was associated with reduced 24-hour estimated blood loss in high-risk obstetric patients, but the optimal dose and timing of TXA administration are still unclear 5.
- The WHO recommends that women with post-partum haemorrhage receive 1 g TXA intravenously as soon as possible after giving birth, followed by a second dose if bleeding continues after 30 min or restarts within 24 h since the first dose 6.
Key Findings
- TXA may not be beneficial for preventing PPH in women at low risk of bleeding 2.
- TXA is most effective when given early, within 3 hours of childbirth 6.
- The optimal dose and timing of TXA administration are still unclear 5.
- There is insufficient evidence to draw conclusions about serious side effects of TXA, such as thromboembolic events and maternal mortality 2, 4.
Considerations for TXA Administration
- The decision to administer TXA after vaginal birth should be based on individual patient risk factors and clinical judgment 3.
- Further research is needed to determine the effectiveness and safety of TXA in preventing PPH in high-risk women and to establish optimal dosing and timing regimens 2, 4, 5, 6.