We found a significant reduction in cEBL in both VD and CD in comparison to the controls and when we performed a logistic regression to control for independent variables, women that received TXA prophylactically had a 2.89 times reduction in PPH. Notably, none of the patients receiving prophylactic TXA required blood products; this has the potential to accrue a significant cost and risk reduction for hospitals and labor and delivery units.
There have been few studies on the prophylactic administration of tranexamic acid to prevent post-partum hemorrhage. (15). According to the WOMAN trial when TXA is administered within 3 hours of diagnosis of post-partum hemorrhage, there was a significant reduction in blood loss(16,17). Leading to the notion of earlier administration of TXA and even prophylactic administration.
A recent systematic review and Cochrane review showed that prophylactic administration of TXA reduced blood loss in low and high-risk deliveries. However, the data was lacking in quality, and the available studies predominantly included low-risk patients (12,18).
Recent completion of the TRAAP trial, Sentilhes et al showed that women undergoing VD who received prophylactic tranexamic acid did not result in the reduction in the rate of estimated blood loss in comparison to placebo(15). One limitation of the was the inclusion of both low and high risk women for PPH, which
We believe the main strength of our study in comparison to previous studies on prophylactic TXA, is our inclusion of moderate to high-risk women only. We believe when TXA was given prophylactically it significantly reduced the cEBL and the rate of PPH in that patient population.
Currently the ACOG guidelines on TXA usage for post-partum hemorrhage, state that TXA should only be used if uterotonics fail to stop the bleeding or if it is thought that the bleeding may be due to trauma (3,19). We believe that TXA should be used prophylactically in select patient populations that are at higher risk for PPH.
Our study had several strengths but some limitations. Even though most of our results were both statistically and clinically significant, a larger population is required to evaluate for adverse events related to TXA administration. We were unable to elicit any side effects associated with TXA administration. However, in previous studies Sentilhes et al and Shakur et al showed no significant increase in the number of serious side effects such as DVT or PE.
Another minor limitation was our inability to control the amount of intravenous fluids the patients received. This could theoretically cause hemodilution affecting the results of the cEBL. However, we assessed the total duration of IV fluid administration and found no significant difference between treatment and control groups.
Finally, given the inherent nature of our study, another potential limitation is physician bias. The knowledge of TXA administration could potentially affect physician management of PPH. Since there was no significant difference between number of uterotonics given, we believe that bias to have been minimal.