Is Tranexamic Acid an Obstetric Life Saver?

Summary and Comment |
May 4, 2017

Is Tranexamic Acid an Obstetric Life Saver?

  1. Robert L. Barbieri, MD

In an international trial, tranexamic acid significantly reduced risk for death from postpartum hemorrhage.

  1. Robert L. Barbieri, MD

In many resource-limited settings, postpartum hemorrhage (PPH) is a key cause of maternal death. Tranexamic acid is an inexpensive lysine analogue that inhibits fibrinolysis, thereby sustaining a developing clot. In an international study of tranexamic acid's effects on risk for maternal death from PPH, 20,060 women were treated with usual measures for PPH and randomized to receive tranexamic acid (1 g as a 10 mg/min intravenous infusion) or placebo. If bleeding continued for 30 more minutes, a second course of tranexamic acid or placebo could be administered. Most participants (96%) received routine uterotonic prophylaxis at delivery; women in both groups were treated with intrauterine tamponade, uterine compression sutures, uterine artery ligation, and/or hysterectomy, as clinically indicated.

Death from bleeding occurred in 1.5% of women who received tranexamic acid versus 1.9% of those who received placebo (adjusted relative risk [RR], 0.78; P=0.03). If treatment was administered within 3 hours after delivery, death rates were 1.2% in the tranexamic acid group versus 1.7% in the placebo group (RR, 0.69; P=0.008). Incidence of other adverse clinical outcomes (e.g., pulmonary embolism, sepsis, eclampsia, organ failure) did not significantly differ between groups.

Comment

Fibrinolysis of the developing clot commonly occurs after PPH and is an important mechanism that underlies continued bleeding. Importantly, this study showed that tranexamic acid was most effective if administered within 3 hours of birth. Prevention of maternal and newborn death is a global health priority, and tranexamic acid can play a role in helping to prevent some deaths caused by PPH in low-resource regions. In the U.S., use of tranexamic acid to manage massive PPH may increase following the publication of these results. Still, the most cost-effective approach to reducing maternal mortality is ensuring access to effective contraception.

Editor Disclosures at Time of Publication

  • Disclosures for Robert L. Barbieri, MD at time of publication Editorial boards UpToDate; OBG Management

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