The Case

A 27-year-old primiparous woman arrives at the emergency department after a prolonged labor at home; she is fully dilated and crowning. She has no significant health history and is only taking prenatal vitamins.

Obstetrics and pediatrics are called stat, but the patient rapidly delivers in the emergency department—a healthy 6-pound, 8-ounce girl with only a first-degree laceration. Pediatrics arrives quickly and provides neonatal assessment. Obstetrics, however, is busy doing an emergency cesarean delivery.

Shortly after the delivery of the placenta, the patient has brisk vaginal bleeding. Her vital signs are normal and stable. Lab tests are requested, and the nurse has already given oxytocin 10 mg IM and started an IV. Knowing that uterine atony is the number-one cause of postpartum hemorrhage (PPH), you start performing fundal massage. While waiting for obstetrics to show up, you think about drugs other than oxytocin that could be used for PPH (methylergonovine, misoprostol, and prostaglandins), and you remember reading something about tranexamic acid (TXA).

Background

TXA is a synthetic analog of the amino acid lysine and acts as an antifibrinolytic agent. It binds to lysine receptor sites on plasminogen, blocking its action on fibrin. The ultimate result is that the fibrin matrix structure is maintained and bleeding is reduced.

PPH is defined by the World Health Organization as “a cumulative blood loss of greater than or equal to 1,000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process.” PPH is one of the leading causes of maternal mortality around the world.¹

The American College of Obstetricians and Gynecologists published guidelines for the management of PPH, including the use of TXA. It gives TXA a Level B recommendation: “Given the mortality reduction findings, tranexamic acid should be considered in the setting of obstetric hemorrhage when initial medical therapy fails.”²

Clinical Question

In women with PPH, does TXA improve survival?

Reference

WOAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017;389(10084):2105-2116.

• Population: Women older than 16 years with a diagnosis of PPH after vaginal birth (>500 mL blood loss) or cesarean delivery (>1,000 mL blood loss) or blood loss causing hemodynamic instability and the clinician was uncertain whether to use TXA.
  • Exclusions: If the clinician felt that TXA would clearly be or not be beneficial.
• Intervention: 1 g TXA slowly infused with the optional second 1 g dose if bleeding continued for 30 minutes or more or stopped and restarted within 24 hours.
• Comparison: Placebo.
• Outcome:
  • Primary: All-cause mortality or hysterectomy within 42 days.
  • Secondary: Mortality due to bleeding, thromboembolic events, surgical interventions, other complications, adverse events, quality-of-life measurements, and thromboembolic events in breastfed babies.

Authors’ Conclusions

“Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset.”

Key Results

They enrolled 20,021 women in the trial. Maternal death occurred in 2.4 percent of all women within 24 hours, and 9 percent of the deaths were within one hour after randomization.