Tranexamic Acid for the Prevention of Blood Loss after Cesarean Delivery
The New England Journal of Medicine:
Postpartum hemorrhage remains a leading cause of severe maternal complications and death worldwide. Prophylactic administration of an uterotonic agent is recommended to reduce the risk of postpartum hemorrhage. Tranexamic acid has emerged in the past decade as another candidate drug to prevent blood loss after childbirth. Tranexamic acid has antifibrinolytic effects that are achieved by promotion of hemostasis through the blocking of lysine-binding sites on plasminogen molecules, and evidence of its clinical effects has been found in various contexts.
Tranexamic acid also reduces bleeding-related mortality among women with postpartum hemorrhage and is consequently recommended worldwide for these patients. Moreover, the survival benefit associated with the earlier administration of the drug in these women suggests that it may prevent coagulopathy after delivery rather than treat it.
TAKE-HOME MESSAGE
In this randomized controlled trial, the researchers investigated the use of tranexamic acid following cesarean delivery for prevention of postpartum hemorrhage.
Patients in the placebo group had higher rates of postpartum hemorrhage compared with those who received tranexamic acid.
Secondary outcomes for postpartum hemorrhage were not different between the two groups. No difference was noted in thromboembolic events up to 3 months following delivery.
Tranexamic acid is becoming a very popular drug in labor and delivery. With some evidence for use after vaginal delivery (although not as strong associations), this new trial for women post-cesarean delivery provides more compelling data for use to reduce postpartum hemorrhage.
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BACKGROUND
Prophylactic administration of tranexamic acid has been associated with reduced postpartum blood loss after cesarean delivery in several small trials, but evidence of its benefit in this clinical context remains inconclusive.
METHODS
In a multicenter, double-blind, randomized, controlled trial, author’s assigned women undergoing cesarean delivery before or during labor at 34 or more gestational weeks to receive an intravenously administered prophylactic uterotonic agent and either tranexamic acid (1 g) or placebo. The primary outcome was postpartum hemorrhage, defined as a calculated estimated blood loss greater than 1000 ml or receipt of a red-cell transfusion within 2 days after delivery. Secondary outcomes included gravimetrically estimated blood loss, provider-assessed clinically significant postpartum hemorrhage, use of additional uterotonic agents, and postpartum blood transfusion.
RESULTS
Of the 4551 women who underwent randomization, 4431 underwent cesarean delivery, 4153 (93.7%) of whom had primary outcome data available. The primary outcome occurred in 556 of 2086 women (26.7%) in the tranexamic acid group and in 653 of 2067 (31.6%) in the placebo group. There were no significant between-group differences in mean gravimetrically estimated blood loss or in the percentage of women with provider-assessed clinically significant postpartum hemorrhage, use of additional uterotonic agents, or postpartum blood transfusion. Thromboembolic events in the 3 months after delivery occurred in 0.4% of women (8 of 2049) who received tranexamic acid and in 0.1% of women (2 of 2056) who received placebo.
CONCLUSIONS
Among women who underwent cesarean delivery and received prophylactic uterotonic agents, tranexamic acid treatment resulted in a significantly lower incidence of calculated estimated blood loss greater than 1000 ml or red-cell transfusion by day 2 than placebo, but it did not result in a lower incidence of hemorrhage-related secondary clinical outcomes.
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