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Meta-Analysis
. 2015 Jun 16;2015(6):CD007872.
doi: 10.1002/14651858.CD007872.pub3.

Tranexamic acid for preventing postpartum haemorrhage

Natalia Novikova  1 , G Justus Hofmeyr, Catherine Cluver
Affiliations
Meta-Analysis

Tranexamic acid for preventing postpartum haemorrhage

Natalia Novikova et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: Postpartum haemorrhage (PPH) is a common and potentially life-threatening complication of labour. Several options for preventing PPH are available, but further advances in this field are important, especially the identification of safe, easy to use and cost-effective regimens. Tranexamic acid (TA), which is an antifibrinolytic agent that is used widely to prevent and treat haemorrhage, merits evaluation to assess whether it meets these criteria.

Objectives: To determine, from the best available evidence, whether TA is effective and safe for preventing PPH in comparison to placebo or no treatment (with or without uterotonic co-treatment), or to uterotonic agents.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 January 2015) and reference lists of retrieved studies.

Selection criteria: All published, unpublished and ongoing randomised controlled trials (RCTs) evaluating the use of TA alone or in addition to uterotonics in the third stage of labour or during caesarean section (CS) to prevent PPH.

Data collection and analysis: Two review authors independently assessed for inclusion all the potential studies identified as a result of the search strategy. We entered the data into Review Manager software and checked for accuracy.

Main results: Twelve trials involving 3285 healthy women at low risk of excessive bleeding undergoing elective CS (nine trials, 2453 participants) or spontaneous birth (three trials, 832 participants) satisfied inclusion criteria and contributed data to the analysis. All participants received routine prophylactic uterotonics in accordance with the local guideline in addition to TA or placebo or no intervention. Overall, included studies had moderate risk of bias for random sequence generation, allocation concealment, blinding, selective reporting and low risk of bias for incomplete data. The quality of evidence was also as assessed using GRADE.Blood loss greater than 400 mL or 500 mL, and more than 1000 mL was less common in women who received TA versus placebo or no intervention (risk ratio (RR) 0.52, 95% confidence interval (CI) 0.42 to 0.63, six trials, 1398 women; moderate quality evidence) and (RR 0.40, 95% CI 0.23 to 0.71, six trials, 2093 women; moderate quality evidence), respectively. TA was effective in decreasing the incidence of blood loss greater than 1000 mL in women who had undergone CS (RR 0.43, 95% CI 0.23, 0.78, four trials, 1534 women), but not vaginal birth (RR 0.28, 95% CI 0.06, 1.36, two trials 559 women). The effect of TA on blood loss greater than 500 mL or 400 mL was more pronounced in the group of women having vaginal birth than in women who had CS. Mean blood loss (from delivery until two hours postpartum) was lower in women who received TA versus placebo or no intervention (mean difference MD - 77.79 mL, 95% CI -97.95, -57.64, five trials, 1186 women) and this effect was similar following vaginal birth and CS.Additional medical interventions (moderate quality evidence) and blood transfusions were less frequent in women receiving TA versus placebo or no interventions. Mild side effects such as nausea, vomiting, dizziness were more common with the use of TA (moderate quality evidence). The effect of TA on maternal mortality, severe morbidity and thromboembolic events is uncertain (low quality evidence).

Authors' conclusions: TA (in addition to uterotonic medications) decreases postpartum blood loss and prevents PPH and blood transfusions following vaginal birth and CS in women at low risk of PPH based on studies of mixed quality. There is insufficient evidence to draw conclusions about serious side effects, but there is an increase in the incidence of minor side effects with the use of TA. Effects of TA on thromboembolic events and mortality as well as its use in high-risk women should be investigated further.

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Conflict of interest statement

None known.

Figures

1
1
Study flow diagram
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
3
3
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
1.1
1.1. Analysis
Comparison 1 Tranexamic acid versus placebo/no treatment, Outcome 1 Blood loss > 400 mL or > 500 mL.
1.2
1.2. Analysis
Comparison 1 Tranexamic acid versus placebo/no treatment, Outcome 2 Blood loss > 1000 mL.
1.3
1.3. Analysis
Comparison 1 Tranexamic acid versus placebo/no treatment, Outcome 3 Mean blood loss (mL).
1.4
1.4. Analysis
Comparison 1 Tranexamic acid versus placebo/no treatment, Outcome 4 Use of additional medical interventions to control PPH.
1.5
1.5. Analysis
Comparison 1 Tranexamic acid versus placebo/no treatment, Outcome 5 Use of additional surgical interventions to control PPH.
1.6
1.6. Analysis
Comparison 1 Tranexamic acid versus placebo/no treatment, Outcome 6 Blood transfusion.
1.7
1.7. Analysis
Comparison 1 Tranexamic acid versus placebo/no treatment, Outcome 7 Maternal death or severe maternal morbidity such as seizure, thromboembolic events, need for intensive care unit admission, hysterectomy, organ failure.
1.8
1.8. Analysis
Comparison 1 Tranexamic acid versus placebo/no treatment, Outcome 8 Side effects.
1.9
1.9. Analysis
Comparison 1 Tranexamic acid versus placebo/no treatment, Outcome 9 Thromboembolic events.
2.1
2.1. Analysis
Comparison 2 Different doses of tranexamic acid, Outcome 1 Blood loss > 400 mL.
2.2
2.2. Analysis
Comparison 2 Different doses of tranexamic acid, Outcome 2 Mean blood loss.
2.3
2.3. Analysis
Comparison 2 Different doses of tranexamic acid, Outcome 3 Use of additional medical interventions to control PPH.
2.4
2.4. Analysis
Comparison 2 Different doses of tranexamic acid, Outcome 4 Side effects.
2.5
2.5. Analysis
Comparison 2 Different doses of tranexamic acid, Outcome 5 Thromboembolic events.
See this image and copyright information in PMC

Update of

Comment in

References

References to studies included in this review

Abdel‐Aleem 2013 {published data only}
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References to studies excluded from this review

Gobbur 2011 {published data only}
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References to studies awaiting assessment

Ahmed 2014 {published data only}
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References to ongoing studies

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