Tranexamic acid for childbirth: why, when, and for whom

How do I manage severe postpartum hemorrhage?

“…The decision to use TXA is at the discretion of the care team on the labor and delivery unit. The maximum dose of TXA is 2 g because of concern that higher doses may increase the risk of renal cortical necrosis in hypoperfused patients …”

“…Further, rates of transfusion (54% in both groups) and the mean number of blood units transfused did not significantly differ between groups. This raises further questions about the potential impact of TXA in reducing PPH‐related morbidity among women who deliver in well‐resourced and well‐staffed hospitals in the developed world …”

Tranexamic acid and obstetric hemorrhage: give empirically or selectively?

“…67 Most other studies, especially in the setting of cesarean section, face several limitations and methodological shortcomings that undermine the conclusions. 39,[59][60][61]63,[68][69][70][71][72][73] The vast majority of these trials had relatively small sample sizes, short follow-up duration (often just until the patient's discharge from the hospital, potentially missing side effects occurring subsequently), and were predominantly single-center studies in developing countries, which limits the generalizability of their findings. Criteria, thresholds and methods used to define and assess PPH varied widely among the trials.…”

“…69,70 These limitations, alongside debates about the clinical significance of reductions in blood loss observed in studies (often in ranges not exceeding 100-200 mL) have undermined the recommendations on routine use of TXA for PPH prophylaxis after vaginal or cesarean deliveries. 38,39 The case for prophylactic use of TXA in cesarean section Most RCTs and meta-analyses 46,[48][49][50][51][52][53][54][55][56][57][58][59][60][61][62][63]67 indicate that the prophylactic administration of TXA is associated with a statistically significant reduction in postpartum blood loss and transfusion among women undergoing cesarean section (although the question as to the clinical significance of the observed reductions in blood loss remains open). 38,39,67 However, as noted, many studies have several limitations that undermine the quality of the evidence.…”

“…24,37 However, several experts have recommended TXA be used as an adjunctive and not a compulsory medication as part of PPH treatment protocols, leaving the decision to the discretion of the care team, with the total dose not exceeding 2 g, while calling for pharmacovigilance surveys to monitor for severe adverse events. 38,39 While most studies have focused on the IV route of administration, the possibility of using alternative routes of administration (oral or topical) had far reaching consequences given the improved access in settings with limited resources. 40 Currently, the evidence supporting the non-parenteral use of TXA in the PPH setting remains limited.…”