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Grand Rounds

New Meta-Analysis: Does Prophylactic TXA Effectively Reduce PPH in Women Undergoing Cesarean?

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BACKGROUND AND PURPOSE:

  • Bellos et al. (AJOG, 2021) assessed the efficacy and safety of prophylactic tranexamic acid (TXA) for the prevention of PPH among women undergoing cesarean delivery

METHODS:

  • Systematic review and meta-analysis
  • Study inclusion criteria
    • RCTs
    • Studies that compared IV TXA to placebo in women undergoing cesarean delivery and receiving standard prophylactic uterotonic agents
  • Study design
    • Meta-analysis was done by fitting random-effects models
    • Subgroup analysis was performed based on
      • Country
      • Protocol availability
      • Double-blinding
      • Risk of bias
      • Sample size
      • TXA dose
    • GRADE criteria used to assess credibility of outcomes
  • Primary outcome
    • Total blood loss (mL) as a continuous variable
  • Secondary outcomes
    • Blood loss >1000 mL
    • Red blood cell transfusion
    • Need of additional uterotonic agent administration
    • Hemoglobin percentage change
    • Thromboembolic event

RESULTS:

  • 10,659 women | 36 studies
  • Dosing
    • TXA was administered at the fixed dose of 1 gram in most studies
    • Weighted adjusted dosing regimen:10 mg/kg (7 trials)
    • No differences found between dosing regimens for
      • Blood loss | Hemoglobin decline | PPH | Transfusion
  • TXA administration was associated with significantly lower
    • Total blood loss
      • Mean difference (MD) -189.44 ml (95% CI, -218.63 to -160.25)
    • Hemoglobin drop
      • MD 8.22% (95% CI, 5.54 to 10.90)
    • Risk of blood loss >1000 ml
      • Odds ratio (OR) 0.37 (95% CI, 0.22 to 0.60)
    • Transfusion requirement
      • OR 0.41 (95% CI, 0.26 to 0.65)
    • Need of additional uterotonics
      • OR 0.36 (95% CI, 0.25 to 0.52)
  • Subgroup analysis indicated a greater effect of TXA on total blood loss reduction in low-middle income countries
  • Outcomes were still stable when women who were at low bleeding risk were evaluated separately
  • The quality of evidence was
    • Moderate for total blood loss and hemoglobin percentage change
    • Low for the other outcomes

CONCLUSION:

  • In this updated meta-analysis, prophylactic TXA was effective at reducing PPH in women undergoing cesarean
  • Results similar to previous Cochrane review: Significant decrease in PPH (moderate quality evidence)
  • The authors state

…the present meta-analysis confirmed and extended the results of previous ones in the field, by including a significantly larger sample size despite the use of strict eligibility criteria, enabling the exploration of heterogeneity and a more accurate appraisal of evidence quality 

Learn More – Primary Sources:

Tranexamic acid for the prevention of postpartum hemorrhage in women undergoing cesarean delivery: an updated meta-analysis

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Related ObG Topics:

TRAAP2 RCT Results: Does Prophylactic Tranexamic Acid Reduce the Risk of Postpartum Hemorrhage After Cesarean?
What is the Optimal Dosage of TXA for Postpartum Hemorrhage Prevention?
Cochrane Review: TXA for Postpartum Hemorrhage – Safe and Effective?

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