Postpartum haemorrhage (PPH) is the leading cause of maternal death worldwide, with approximately 100 000 deaths per year (World Health Organization, 2013). PPH is also a leading cause of maternal morbidity in the UK and the top cause of postnatal admissions to intensive care units (Intensive Care National Audit and Research Centre, 2012).
It is with great interest that I read a study about the effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with PPH (WOMAN Trial collaborators, 2017). Even though this was an international study in low resource settings, I wondered what we could learn for our own practice.
Background
Tranexamic acid is an antifibrinolytic drug that primarily works by inhibiting the breakdown of clots (fibrinolysis). Early activation of fibrinolysis is common after trauma and is associated with increased mortality (Sawamura et al, 2009). Previous studies have found that serum concentrations of tissue plasminogen activator double in the first hour after birth, probably due to tissue damage at birth (Kruithof et al, 1987).
This study took place between March 2010–April 2016, and enrolled 20 060 women, who were randomised at the point of PPH to receive either intravenous tranexamic acid after the usual uterotonic drugs had been administered, or a placebo. The trial was double blind, so neither the health professionals nor the women knew which drug was administered at the point of randomisation.
Findings
The researchers looked at several different outcomes. Death associated with bleeding was significantly reduced in the tranexamic acid group (155 of 10036; 1.5%) versus the placebo group (191 of 9985; 1.9%; P=0.045). This was especially noticed in women receiving tranexamic acid within 3 hours of birth (n=89; 1.2%) versus the placebo group (n=127; 1.7%; P=0.008). After 3 hours there was no benefit.
Hysterectomy was not reduced in the tranexamic acid group (n=358; 3.6%) versus the placebo group (n=351; 3.5%; P=0.65). The researchers reasoned that the decision to perform hysterectomy was often done at the point of randomisation, meaning that, in low resource settings where women may be anaemic or where there is a limited supply of blood transfusions, hysterectomy is often an early intervention.
The authors noted that many deaths from PPH occurred in the community or home setting where intravenous tranexamic acid was not feasible, and recommended more research into whether alternative routes would be feasible in the home setting.
This is an important study that recruited women from 193 hospitals in 21 countries. The researchers concluded that when used for the treatment for PPH, tranexamic acid should be given as soon as possible after the onset of bleeding.
In December 2016, the Royal College of Obstetricians and Gynaecologists (RCOG) updated the guidance on PPH, stating that tranexamic acid should be considered in the management of PPH (Mavrides et al, 2016).
Conclusions
This is an important study, showing significant evidence for the use of tranexamic acid in reducing global maternal deaths. This is a real positive for women in low-resource countries, and for the devastation of maternal death.
This study has highlighted the dangers that women in low-resource countries face on a daily basis and this is one of the main reasons why I am writing this blog: to support and circulate this amazing work.
It is difficult to say whether the results would have been the same in the UK, which has a lower rate of morbidity and mortality. Nevertheless, with no recorded adverse effects, and with recommendations from the RCOG, tranexamic acid should be considered in all cases of PPH.