As a member of your hospital’s maternal safety committee, you are asked to review prevention strategies for maternal hemorrhage during cesarean delivery. According to a recent study of patients undergoing cesarean delivery, the addition of tranexamic acid (1 g) compared to use of uterotonic medication alone would MOST likely result in which of the following outcomes?
(A) Increased rate of blood loss greater than 1,000 mL postpartum X
(B) Decreased use of additional uterotonic agents X
(C) Similar rate of postpartum blood transfusion ✔
Read the discussion below.
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Postpartum hemorrhage is one of the leading causes of maternal mortality globally. The role of prophylactic uterotonics as first-line medications to decrease postpartum hemorrhage after delivery is well established. The use of the antifibrinolytic tranexamic acid (TXA) as a therapeutic agent for postpartum hemorrhage after vaginal and cesarean deliveries has also been established. However, the role of prophylactic use of TXA to decrease the rate and amount of postpartum hemorrhage during a cesarean delivery is less well defined.
A recent multicenter, randomized, placebo-controlled, double-blind trial compared patients who received prophylactic uterotonic and TXA (1 g) (n = 2,086) with patients who received prophylactic uterotonic and a placebo (n = 2,067) during cesarean delivery; study participants included both laboring and non-laboring patients at or above 34 weeks’ gestation. The primary outcome was postpartum hemorrhage, defined as a calculated estimated blood loss greater than 1,000 mL or a red-cell transfusion within 2 days after delivery. Secondary outcomes included clinical and laboratory (blood samples at day 2) measurements of postpartum blood loss, adverse events determined by the investigators to be potentially related to TXA, maternal satisfaction on day 2, and psychological status at 2 months (as assessed with the Edinburgh Postnatal Depression Scale [EPDS]). Two predetermined subgroup analyses were used to assess the effect of TXA on postpartum hemorrhage according to the timing of the cesarean delivery (before or during labor) and the women’s postpartum hemorrhage risk status.
The primary outcome of postpartum hemorrhage occurred in 26.7% of women in the TXA group and 31.6% in the placebo group (adjusted risk ratio, 0.84; 95% CI, 0.75–0.94). Sensitivity analysis with complete cases showed similar results.
In the subgroup analysis for the primary outcome of postpartum hemorrhage, no evidence was found indicating differential effects of TXA according to timing of delivery or the presence or absence of risk factors for postpartum hemorrhage.
In terms of secondary outcomes, there were no between-group differences in the rate of mean gravimetrically estimated blood loss, provider-assessed clinically significant hemorrhage, use of additional uterotonic agents for excessive bleeding, postpartum blood transfusion, or arterial embolization or emergency surgery. Maternal satisfaction and EPDS scores at 2 months were also similar between the 2 groups.
In summary, the administration of prophylactic uterotonic and TXA in women undergoing cesarean delivery resulted in a lower rate of postpartum hemorrhage greater than 1,000 mL and did not result in increased need for red blood cell transfusion.
1. Sentilhes L, Sénat MV, Le Lous M, et al. Tranexamic acid for the prevention of blood loss after cesarean delivery. N Engl J Med. 2021;384(17):1623-1634. doi:10.1056/NEJMoa2028788
2. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017;389(10084):2105-2116. doi:10.1016/S0140-6736(17)30638-4
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