The role of tranexamic acid in the management of postpartum haemorrhage

Tranexamic Acid in Pregnant Women With Placenta Previa: A Double-Blind, Multicenter Randomized Clinical Trial

AIMS

To determine the effectiveness of tranexamic acid (TXA) in reducing vaginal bleeding, extending pregnancy duration, and enhancing perinatal outcomes in pregnant women with placenta previa.

METHODS

A multicenter, randomized, double-blind clinical trial was conducted at three maternity teaching hospitals in Iraq's Kurdistan region, Azadi Hospital in the north of Iraq, and Al-Azhar University Hospital in Egypt on 146 women with placenta previa. Participants were randomly assigned to two interventional groups in a 1:1 ratio to receive either TXA or Dextrose 5% water (D5W). The two groups were compared in terms of the cessation of vaginal bleeding, continuation of pregnancy to term, and the perinatal outcome after repeated use of either method of treatment.

RESULTS

Bleeding stopped in 91.8% of the TXA group; however, the placebo group had more admissions for blood transfusion, received more units of packed red blood cells, and almost all their deliveries were preterm compared with the TXA group. Factors significantly associated with 'stopped bleeding' were TXA (OR = 5.2; 95% CI = 1.7-15.5), BMI of < 25 kg/m2 (OR = 6.3; 95% CI = 1.2-35.5), and BMI of 25-29 kg/m2, late preterm delivery (32-36+6 weeks) [OR = 20.6; 95% CI = 4.6-90.2], and term delivery (39-40+6 weeks) [OR = 4.5; 95% CI = 4.5-776.2] compared with very preterm deliveries (28-32+6 weeks).

CONCLUSIONS

 Treatment with TXA during pregnancy in women with placenta previa significantly outperforms in managing vaginal bleeding, prolonging pregnancy to a favorable gestational age and perinatal outcome. Larger studies are needed to confirm its benefits and guide clinical practice.

Awareness and use of tranexamic acid in the management of postpartum hemorrhage among health care professionals in Enugu, Nigeria

OBJECTIVES

This study was conducted to determine the knowledge, practice, and barriers regarding the use of tranexamic acid (TXA) for the prevention and treatment of postpartum hemorrhage (PPH) among health care providers in Enugu, Nigeria.

METHODS

A cross-sectional study was conducted among health professionals (doctors, pharmacists, and nurses) in two Nigerian tertiary teaching hospitals (one federal and one state). A total of 220 questionnaires were distributed and 207 were returned (response rate: 94%) and analyzed using SPSS for inferential statistics with a level of significance of P < 0.05.

RESULTS

Only 23.7% of the respondents had good knowledge of TXA use in PPH (P < 0.001), and awareness of the recent World Health Organization (WHO) recommendation on the use of TXA for PPH was low (19.8%, P < 0.001). The majority of the respondents had neither prescribed nor dispensed TXA (30%, P < 0.001). Very few respondents used TXA for all cases of PPH (16.4%, P < 0.001). Barriers against its use include nonawareness of the latest WHO recommendation, preference for other uterotonics, and cost of the drug.

CONCLUSIONS

There was poor knowledge of TXA, poor awareness of its recommendation, and low use for PPH among different cadres of health care providers.

Women with severe postpartum hemorrhage have a decreased endogenous thrombin potential before delivery

BACKGROUND

Severe postpartum hemorrhage (PPH), defined as a blood loss ≥1000 mL, is associated with maternal morbidity and mortality.

OBJECTIVES

We aimed at characterizing coagulation properties of predelivery plasmas from pregnant women with thrombin generation assay and hemostatic biomarkers (plasminogen activator inhibitor-1, tissue factor [TF], and thrombomodulin).

METHODS

A nested case-control study was conducted within the "Study of Biological Determinants of Bleeding Postpartum," a French prospective cohort study, in order to compare women with severe PPH (cases) and controls matched for age, body mass index, term, and mode of delivery. Plasma was collected at entry in the delivery room, and blood loss was measured objectively. The predelivery endogenous thrombin generation potential (ETP) was measured in plasma using calibrated automated thrombinography and low TF concentration. Hemostatic biomarkers were measured using ELISA kits.

RESULTS

A total of 142 women (71 cases and 71 controls) were investigated. There was no difference in the median lag phase, thrombin peak, and time to peak between cases and controls. However, median predelivery ETP was lower in cases than in controls (2170 vs 2408 nM.min, P < .0001), independently of mode of delivery and PPH etiology. Median plasminogen activator inhibitor-1 and TF levels were higher in cases compared with controls (107.4 vs 68.1 ng/mL, P = .0003; 34.4 vs 27.4 pg/mL, P = .007), whereas thrombomodulin levels did not differ between the 2 groups.

CONCLUSION

Among thrombin generation assay parameters, predelivery ETP levels may have a predictive value for severe PPH.

Tranexamic Acid Was Not Associated With a Reduction in Bleeding Complications Related to Holmium Laser Enucleation of the Prostate

OBJECTIVE

To compare outcomes in males given perioperative tranexamic acid (TXA) during holmium laser enucleation of the prostate (HoLEP) to a historical cohort that did not receive TXA.

METHODS

Our cohort included HoLEP patients (N = 1037) from August 2018 through November 2022. Exclusion criteria included history of stroke, transient ischemic attack, or coronary stent placed within 18 months. The primary predictor was TXA during HoLEP. The primary outcome variable was a return to the operating room (RTOR) for bleeding. Secondary outcomes included catheter reinsertion, transfusion, and clotting complications. Multivariable models evaluating associations of TXA with outcomes were adjusted for potential confounders.

RESULTS

In our cohort, 214/1035 had one or more complications with 81 having a Clavien-Dindo Grade of 3a or higher, 114/1037 with catheter reinsertion, 36/1037 RTOR for bleeding, and 15/1035 had a transfusion. TXA use was not associated with 30-day RTOR. 3.7% of those without TXA had a RTOR, and 3.1% of those with TXA had a RTOR (adjusted odds ratio 0.63, 95% CI 0.28-1.38, P = .25). Transfusion rates were higher for those without TXA (2.0%) compared to with (0.5%). This was statistically significant after adjustment (adjusted odds ratio 0.13, 95% CI 0.03-0.69, P = .016) and after correction for multiple testing (corrected P = .048). TXA use was not associated with catheter reinsertion or clotting complications.

CONCLUSION

Routine perioperative intravenous TXA in HoLEP patients was not associated with a reduction of RTOR for bleeding, catheter reinsertion, or clotting complications. TXA was associated with decreased transfusions with a low overall event rate of 1.4%.