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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