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Grand Rounds

Does Prophylactic TXA Reduce Postpartum Hemorrhage?

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BACKGROUND AND PURPOSE:

  • TXA, based on evidence, is an effective treatment for PPH (see related ‘Related ObG Topics’ below)
  • Sentilhes et al. (NEJM, 2018) examined whether addition of prophylactic administration of tranexamic acid (TXA) vs oxytocin reduces incidence of postpartum hemorrhage

METHODS:

  • Multicenter, double-blind, randomized, controlled trial (RCT)
  • Participants
    • ≥18 years, singleton pregnancy
    • ≥35w0d
    • Planning vaginal delivery
  • Women were randomized to one of the following
    • 1g TXA IV
    • Matched placebo
  • Procedure
    • IV slowly administered over 30 – 60 seconds during the 2 minutes after delivery after routine prophylactic oxytocin IV at delivery of the anterior shoulder and clamping of the umbilical cord
  • Statistical analysis
    • Power calculation: 3628 women with a vaginal delivery would provide a power of at least 90%
  • Primary outcome
    • PPH (≥ 500 ml)
    • Objective collection device
  • Secondary outcomes
    • Multiple additional PPH outcomes (e.g., blood loss >500 ml and at least 1000 ml, total EBL, proportion of women requiring supplementary uterotonics etc.)

RESULTS:

  • 3,891 women had a vaginal delivery on the study
    • 1945 TXA group | 1946 placebo group

Primary Outcome – PPH

  • There was no difference between the TXA group (8.1%) vs placebo group (9.8%)
    • Relative risk (RR) 0.83; 95% CI, 0.68 to 1.01 (P=0.07)

Secondary Outcomes

  • Women in the TXA group (7.8%) had a lower rate of provider-assessed clinically significant postpartum hemorrhage vs placebo group (10.4%)
    • RR 0.74; 95% CI, 0.61 to 0.91 (adjusted P=0.04)
  • Women in TXA group (7.2%) received additional uterotonic agents less often compared to placebo group (9.7%)
    • RR 0.75; 95% CI, 0.61 to 0.92 (adjusted P=0.04)
  • The incidence of thromboembolic events in the 3 months after delivery did not differ between groups
  • Other Secondary outcomes: No differences between groups

CONCLUSION:

  • The addition of tranexamic acid did not significantly reduce rates of PPH (≥ 500 ml) for women who delivered vaginally and had received prophylactic oxytocin
  • Further trials are required to assess the role for prophylactic TXA for cesarean delivery

Learn More – Primary Sources:

Tranexamic Acid for the Prevention of Blood Loss after Vaginal Delivery

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Related ObG Topics:

Results From the Landmark Trial on Tranexamic Acid for Postpartum Hemorrhage
Postpartum Hemorrhage – Medications to Treat Uterine Atony 
How does TXA Measure Up as a Treatment for Menorrhagia?

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