section name header

Evidence summaries

Tranexamic Acid for Preventing Postpartum Haemorrhage

Tranexamic acid decreases postpartum blood loss after caesarean section but not in vaginal birth compared with placebo or no treatment, without increasing thromboembolic events. Level of evidence: "A"

A Cochrane review [Abstract]1 assessing prophylactic tranexamic acid (TXA) for prevention of postpartum haemorrhage (PPH) following vaginal birth included 3 RCTs with a total of 18 974 participants. There was little or no difference in blood loss ≥ 500 mL (RR 0.93, 95% CI 0.81 to 1.06; 2 studies, n=18 897; high-certainty evidence), blood loss ≥ 1000 mL (RR 0.86, 95% CI 0.69 to 1.07; 2 studies, n=18 897; moderate-certainty evidence), and receipt of blood transfusion (RR 1.00, 95% CI 0.95 to 1.06; 3 studies, n=18 972; high-certainty evidence).

A systematic review and meta-analysis 5 assessed whether prophylactic intravenous TXA prevents PPH and/or transfusions following cesarean delivery. TXA led to significantly less risk of PPH (RR 0.43, 95% CI 0.28 to 0.67) and blood transfusion (RR 0.39, 95% CI 0.2 to 0.73). Heterogeneity was minimal (I²=0%).

A meta-analysis 3 included 18 RCTs with 3846 subjects, with 1935 patients receiving tranexamic acid (TXA). The studies were of poor to moderate quality. Prophylactic TXA administration was associated with a decreased incidence of PPH after delivery (odds ratio [OR], 0.32; 95% CI, 0.17 to 0.59; P = .0006), a reduction in mean blood loss by 149.1mL (95% CI, 112.9 to 185.2; P < .00001), and a reduction in red blood cell transfusions (OR, 0.28; 95% CI, 0.15 to 0.49; P < .00001) while also being associated with a reduction in the use of additional uterotonics (OR, 0.45; 95% CI, 0.30 to 0.66; P < .00001). Minor side effects were more common in those who received TXA (OR, 2.51; 95% CI, 1.69-3.74; P < .00001). There appeared to be no increased risk of venous thromboembolism and no difference in length of hospital stay associated with TXA use.

Another meta-analysis 2 included 25 RCTs with 4747 subjects. TXA resulted in a reduced intra-, postoperative, and total blood loss by a mean volume of 141.25 mL (95% CI -186.72 to -95.79, P < 0.00001), 36.42 mL (95% CI -46.50 to -26.34, P < 0.00001), and 154.25 mL (95% CI -182.04 to -126.47, P < 0.00001) in caesarean section. TXA administration in vaginal delivery was associated with a reduced intra-, postoperative, and total blood loss by a mean volume of 22.88 mL (95% CI -50.54 to 4.77, P = 0.10), 41.24 mL (95% CI -55.50 to -26.98, P < 0.00001), and 84.79 mL (95% CI -109.93 to -59.65, P < 0.00001). In addition, TXA could lower the occurrence rate of PPH and severe PPH, and reduce the risk of blood transfusions. No increased risk of deep vein thrombosis was associated with TXA usage.

A multicenter, double-blind, randomized, controlled trial 4 included 3891 subjects. The primary outcome off PPH occurred in 156/1921 women (8.1%) in the TXA group and in 188/1918 (9.8%) in the placebo group (RR 0.83; 95% CI, 0.68 to 1.01; P=0.07). TXA group had a lower rate of provider-assessed clinically significant PPH than those in the placebo group (7.8% vs. 10.4%; RR 0.74; 95% CI, 0.61 to 0.91; P=0.004; P=0.04 after adjustment for multiple comparisons post hoc) and also received additional uterotonic agents less often (7.2% vs. 9.7%; RR 0.75; 95% CI, 0.61 to 0.92; P=0.006; adjusted P=0.04). Other secondary outcomes did not differ significantly between the two groups. The incidence of thromboembolic events in the 3 months after delivery did not differ significantly between the TXA and the placebo (0.1% and 0.2%, respectively; relative risk, 0.25; 95% CI, 0.03 to 2.24).

    References

    • Rohwer C, Rohwer AC, Cluver C, et al. Tranexamic acid for preventing postpartum haemorrhage after vaginal birth. Cochrane Database Syst Rev 2025;1(1):CD007872 [PubMed]
    • Li C, Gong Y, Dong L et al. Is prophylactic tranexamic acid administration effective and safe for postpartum hemorrhage prevention?: A systematic review and meta-analysis. Medicine (Baltimore) 2017;96(1):e5653. [PubMed]
    • Alam A, Choi S. Prophylactic Use of Tranexamic Acid for Postpartum Bleeding Outcomes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Transfus Med Rev 2015;29(4):231-41. [PubMed]
    • Sentilhes L, Winer N, Azria E et al. Tranexamic Acid for the Prevention of Blood Loss after Vaginal Delivery. N Engl J Med 2018;379(8):731-742. [PubMed]
    • Lee A, Wang MY, Roy D, et al. Prophylactic Tranexamic Acid Prevents Postpartum Hemorrhage and Transfusions in Cesarean Deliveries: A Systematic Review and Meta-analysis. Am J Perinatol 2024;41(S 01):e2254-e2268. [PubMed]

Primary/Secondary Keywords