Journal Club presented at Dept. of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Delhi. World Maternal Anti-fibrinolytic Trial

1. 31.08.2017
JOURNAL CLUB Candidate: Dr Amenda Davis
Consultant Guide: Dr Aparna Sharma
SR Guide: Dr Plabani Sarkar

2. Haleema Shakur, Ian Roberts, Bukola Fawole, Rizwana Chaudhri,Mohamed El-Sheikh, Adesina Akintan, Zahida Qureshi, Hussein Kidanto, Bellington Vwalika, Abdulfetah Abdulkadir, Saturday Etuk, Shehla Noor, Etienne Asonganyi, Zarko Alfirevic,
Danielle Beaumont, Carine Ronsmans, Sabaratnam Arulkumaran, Adrian Grant, Kaosar Afsana, Metin Gülmezoglu, Beverley Hunt, Oladapo Olayemi, Ian Roberts, Iain Chalmers, Pisake Lumbiganon, Gilda Piaggio, Tony Brady, Haleema Shakur, Ian Roberts, Zarko Alfirevic, Diana Elbourne, Metin Gülmezoglu, Carine Ronsmans, Eni
Balogun, Tracey Pepple, Danielle Prowse, Nigel Quashi, Lin Barneston, Collette Barrow, Danielle Beaumont, Lisa Cook, Lauren Frimley, Daniel Gilbert, Catherine Gilliam, Rob Jackson, Taemi Kawahara, Hakim Miah, Sergey Kostrov, Maria Ramos, Ian Roberts, Haleema Shakur, Phil Edwards, Tom Godec, Sumaya Huque, Bukola Fawole,
Olujide Okunade, Olusade Adetayo, Rizwana Chaudhri, Aasia Kayani, Kiran Javaid, Bukola Fawole, Rizwana Chaudhri, Chrstine Biryabarema, Zahida Qureshi, Robert Tchounzou, Mohamed El-Sheikh, Hussein Kidanto, Mohan Regmi, Bellington Vwalika, Kastriot Dallaku, Mateus Sahani, Sayeba Akhter, Abdulfetah Abdulkadir, Nicolas
Meda, Anthony Kwame Dah, Adesina Akintan, Olufemi Odekunle, Oluwabusola Monehin, Austin Ojo, Grace Akinbinu, Ifeoma Offiah, Saturday Etuk, Ubong Akpan, Uduak Udofia, Useneno Okon, Ezukwa Omoronyia, Okpe James, Oladapo Olayemi, Nike Bello, Blessed Adeyemi, Chris Aimakhu, Olufemi Akinsanya, Bamidele Adeleye,
Oluwaseun Adeyemi, Kayode Oluwatosin, Abiodun Aboyeji, Abiodun Adeniran, Adebayo Adewale, Noah Olaomo, Lawrence Omo-Aghoja, Emmanuel Okpako, Lucky Oyeye, Francis Alu, John Ogudu, Ezekiel Ladan, Ibrahim Habib, Babasola Okusanya, Olatunde Onafowokan, David Isah, Abalaka Aye, Felix Okogbo, Egbaname Aigere, Mark
Ogbiti, Temitope Onile, Olaide Salau, Yinka Amode, Kamil Shoretire, Adebola Owodunni, Kehinde Ologunde, Akintunde Ayinde, Moses Alao, Olalekan Awonuga, Babatunde Awolaja, Omololu Adegbola, Fatimah Habeebu-Adeyemi, Adeyemi Okunowo, Hadiza Idris, Ola Okike, Nneka Madueke, Josiah Mutihir, Nankat Joseph, Babatunde
Adebudo, Adeniyi Fasanu, Olugbenga Akintunde, Olufemi Abidoye, Owigho Opreh, Sophia Udonwa, Gladys Dibia, Simeon Bazuaye, Arafat Ifemeje, Aniefiok Umoiyoho, Emmanuel Inyang-Etoh, Sununu Yusuf, Kayode Olayinka, Babalola Adeyemi, Olusegun Ajenifuja, Umar Ibrahim, Yusuf Baffah Adamu, Oluwarotimi Akinola, Grace
Adekola-Oni, Paul Kua, Roseline Iheagwam, Audu Idrisa, Ado Geidam, Andrea Jogo, Joseph Agulebe, Joseph Ikechebelu, Onyebuchi Udegbunam, Jacob Awoleke, Oluseyi Adelekan, Hajaratu Sulayman, Nkeiruka Ameh, Nurudeen Onaolapo, Affiss Adelodun, William Golit, Dachollom Audu, Adetunji Adeniji, Folasade Oyelade, Lamaran
Dattijo, Palmer Henry, Babalola Adeyemi, Olabisi Loto, Odidika Umeora, Abraham Onwe, Emily Nzeribe, Bartthy Okorochukwu, Augustine Adeniyi, Emmanuel Gbejegbe, Akpojaro Ikpen, Ikemefuna Nwosu, Abdulrasaq Sambo, Olubunmi Ladipo, Sola Abubakar, Ola Nene Okike, Enyinnaya Chikwendu Nduka, Eziamaka Pauline Ezenkwele,
Daniel Onwusulu, Theresa Azonima Irinyenikan, Swati Singh, Amaitari Bariweni, Hadiza Galadanci, Peter Achara, Osagie Osayande, Mohammed Gana, Rizwana Chaudhri, Kiran Jabeen, Ayesha Mobeen, Sadaf Mufti, Maliha Zafar, Shehla Noor, Basharat Ahmad, Maimoona Munawar, Jeharat Gul, Naseema Usman, Fehmida Shaheen,
Mariam Tariq, Nadia Sadiq, Rabia Batool, Habiba Sharaf Ali, Manahil Jaffer, Asma Baloch, Noonari Mukhtiar, Tasneem Ashraf, Raheela Asmat, Salma Khudaidad, Ghazala Taj, Roshan Qazi, Saira Dars, Faryal Sardar, Sanobar Ashfaq, Saeeda Majeed, Sadaqat Jabeen, Rukhsana Karim, Farzana Burki, Syeda Rabia Bukhari, Fouzia Gul, Musarrat
Jabeen, Akhtar Sherin, Qurratul Ain, Shahid Rao, Uzma Shaheen, Samina Manzoor, Shabween Masood, Shabana Rizvi, Anita Ali, Abida Sajid, Aisha Iftikhar, Shazia Batool, Lubna Dar, Shahenzad Sohail, Shazia Rasul, Shamsa Humayun, Rashida Sultana, Sofia Manzoor, Syeda Mazhar, Afshan Batool, Asia Nazir, Nasira Tasnim, Hajira
Masood, Razia Khero, Neelam Surhio, Samana Aleem, Naila Israr, Saba Javed, Lubna Bashir, Samina Iqbal, Faiza Aleem, Rubina Sohail, Saima Iqbal, Samina Dojki, Alia Bano, Naseem Saba, Maimoona Hafeez, Nishat Akram, Naila Israr, Riffat Shaheen, Haleema Hashmi, Sharmeen Arshad, Rubina Hussain, Sadia Khan, Nighat Shaheen, Safia
Khalil, Pushpa Sachdev, Gulfareen Arain, Amtullah Zarreen, Sara Saeed, Shamayela Hanif, Nabia Tariq, Mahwish Jamil, Shama Chaudhry, Hina Rajani, Tayyiba Wasim, Summera Aslam, Nilofar Mustafa, Huma Quddusi, Sajila Karim, Shazia Sultana, Misbah Harim, Mohd Chohan, Nabila Salman, Fareesa Waqar, Shamsunnisa Sadia, Lubna
Kahloon, Shehla Manzoor, Samar Amin, Umbreen Akram, Ambreen Ikram, Samina Kausar, Tahira Batool, Brigadier Naila, Tahir Kyani, Christine Biryabarema, Ruth Bulime, Regina Akello, Bernadette Nakawooya Lwasa, Joselyn Ayikoru, Christine Namulwasira, Patrick Komagum, Isabirye Rebecca, Nayiga Annet, Nakirigya Nuulu, Elizabeth
Nionzima, Rose Bwotya, Margret Nankya, Sarah Babirye, Joseph Ngonzi, Cesar Sanchez, Nkonwa Innocent, Kusasira Anitah, Ayiko Jackson, Elizabeth Ndagire, Christine Nanyongo, Dominic Drametu, Grace Meregurwa, Francis Banya, Rita Atim, Emmanuel Byaruhanga, Lema Felix, Hussein Iman, Vincent Oyiengo, Peninah Waigi, Rose
Wangui, Faiza Nassir, Musimbi Soita, Rophina Msengeti, Zeinab Zubier, Hillary Mabeya, Antony Wanjala, Henry Mwangi, Brian Liyayi, Evelyn Muthoka, Alfred Osoti, Amos Otara, Veronicah Ongwae, Zahida Qureshi, Victor Wanjohi, Bonface Musila, Kubasu Wekesa, Alex Nyakundi Bosire, Etienne Asonganyi, Alice Ntem, Angeline
Njoache, Alice Ashu, André Simo, Robert Tchounzou, Dorothy Keka, Kenfack Bruno, Amadou Ndouoya, Martin Saadio, Mesack Tchana, Odel Gwan, Pauline Assomo, Venantius Mutsu, Nji Eric, Pascal Foumane, Philemon Nsem, Jeanne Fouedjio, Ymele Fouelifack, Pierre Marie Tebeu, Georges Nko'ayissi, Eta Ngole Mbong, Wisal Nabag,
Riham Desougi, Hadia Mustafa, Huida Eltaib, Taha Umbeli, Khalid Elfadl, Murwan Ibrahim, Abdalla Mohammed, Awadia Ali, Somia Abdelrahiem, Mohammed Musa, Khidir Awadalla, Samirra Ahmed, Mahdi Bushra, Omer Babiker, Hala Abdullahi, Mohamed Ahmed, Dr. Elhassan Safa, Dr. Huida Almardi, Duria Rayis, Saeed Abdelrahman
Abdelgabar, Zarko Alfirevic, Gillian Houghton, Andrew Sharpe, Jim Thornton, Nick Grace, Carys Smith, Kim Hinshaw, Dawn Edmundson, Paul Ayuk, Alison Bates, George Bugg, Joanne Wilkins, Clare Tower, Alysha Allibone, Eugene Oteng-Ntim, Hussein Kidanto, Ahmad Kazumari, Anna Danford, Matilda Ngarina, Muzdalifat Abeid,
Khadija Mayumba, Magreth Zacharia, George Mtove, Leonard Madame, Anthony Massinde, Berno Mwambe, Rwakyendela Onesmo, Sebastian Kitengile Ganyaka, Mohan Regmi, Shyam Gupta, Rabindra Bhatt, Ajay Agrawal, Pramila Pradhan, Nikita Dhakal, Punita Yadav, Gyanendra Karki, Bhola Ram Shrestha, Bellington Vwalika, Mwansa
Lubeya, Jane Mumba, Willies Silwimba, Isaiah Hansingo, Noojiri Bopili, Ziche Makukula, Alexander Kawimbe, Mwansa Ketty Lubeya, Willard Mtambo, Mathew Ng'ambi, Kastriot Dallaku, Saimir Cenameri, Ilir Tasha, Aferdita Kruja, Besnik Brahimaj, Armida Tola, Leon Kaza, Mateus Sahani, Desire Tshombe, Elizabeth Buligho, Roger
Paluku-Hamuli, Charles Kacha, Kato Faida, Badibanga Musau, Herman Kalyana, Phanny Simisi, Serge Mulyumba, Nzanzu Kikuhe Jason, Jean Robert Lubamba, Willis Missumba, Ferdousi Islam, Nazneen Begum, Sayeba Akhter, Ferdousi Chowdhury, Rokeya Begum, Farjana Basher, Nazlima Nargis, Abu Kholdun, Shahela Jesmin, Shrodha
Paul, Hailemariam Segni, Getachew Ayana, William Haleke, Abdulfetah Abdulkadir, Hassen Hussien, Fikre Geremew, Moussa Bambara, Adolphe Somé, Amadou Ly, Roamba Pabakba, Horace Fletcher, Leslie Samuels, Henry Opare-Addo, Roderick Larsen-Reindorf, Kwadwo Nyarko-Jectey, Glen Mola, Malts Wai, Magdy El Rahman, Wafaa
Basta, Hussein Khamis, Maria Fernanda Escobar, Liliana Vallecilla, Gabriel Essetchi Faye Haleema Shakur, Ian Roberts, Bukola Fawole, Rizwana Chaudhri, Mohamed El-Sheikh, Adesina Akintan, Zahida Qureshi, Hussein Kidanto, Bellington Vwalika, Abdulfetah Abdulkadir, Saturday Etuk, Shehla Noor, Etienne Asonganyi, Zarko Alfirevic,
Danielle Beaumont, Carine Ronsmans, Sabaratnam Arulkumaran, Adrian Grant, Kaosar Afsana, Metin Gülmezoglu, Beverley Hunt, Oladapo Olayemi, Ian Roberts, Iain Chalmers, Pisake Lumbiganon, Gilda Piaggio, Tony Brady, Haleema Shakur, Ian Roberts, Zarko Alfirevic, Diana Elbourne, Metin Gülmezoglu, Carine Ronsmans, Eni
Balogun, Tracey Pepple, Danielle Prowse, Nigel Quashi, Lin Barneston, Collette Barrow, Danielle Beaumont, Lisa Cook, Lauren Frimley, Daniel Gilbert, Catherine Gilliam, Rob Jackson, Taemi Kawahara, Hakim Miah, Sergey Kostrov, Maria Ramos, Ian Roberts, Haleema Shakur, Phil Edwards, Tom Godec, Sumaya Huque, Bukola Fawole,
Olujide Okunade, Olusade Adetayo, Rizwana Chaudhri, Aasia Kayani, Kiran Javaid, Bukola Fawole, Rizwana Chaudhri, Chrstine Biryabarema, Zahida Qureshi, Robert Tchounzou, Mohamed El-Sheikh, Hussein Kidanto, Mohan Regmi, Bellington Vwalika, Kastriot Dallaku, Mateus Sahani, Sayeba Akhter, Abdulfetah Abdulkadir, Nicolas
Meda, Anthony Kwame Dah, Adesina Akintan, Olufemi Odekunle, Oluwabusola Monehin, Austin Ojo, Grace Akinbinu, Ifeoma Offiah, Saturday Etuk, Ubong Akpan, Uduak Udofia, Useneno Okon, Ezukwa Omoronyia, Okpe James, Oladapo Olayemi, Nike Bello, Blessed Adeyemi, Chris Aimakhu, Olufemi Akinsanya, Bamidele Adeleye,
Oluwaseun Adeyemi, Kayode Oluwatosin, Abiodun Aboyeji, Abiodun Adeniran, Adebayo Adewale, Noah Olaomo, Lawrence Omo-Aghoja, Emmanuel Okpako, Lucky Oyeye, Francis Alu, John Ogudu, Ezekiel Ladan, Ibrahim Habib, Babasola Okusanya, Olatunde Onafowokan, David Isah, Abalaka Aye, Felix Okogbo, Egbaname Aigere, Mark
Ogbiti, Temitope Onile, Olaide Salau, Yinka Amode, Kamil Shoretire, Adebola Owodunni, Kehinde Ologunde, Akintunde Ayinde, Moses Alao, Olalekan Awonuga, Babatunde Awolaja, Omololu Adegbola, Fatimah Habeebu-Adeyemi, Adeyemi Okunowo, Hadiza Idris, Ola Okike, Nneka Madueke, Josiah Mutihir, Nankat Joseph, Babatunde
Adebudo, Adeniyi Fasanu, Olugbenga Akintunde, Olufemi Abidoye, Owigho Opreh, Sophia Udonwa, Gladys Dibia, Simeon Bazuaye, Arafat Ifemeje, Aniefiok Umoiyoho, Emmanuel Inyang-Etoh, Sununu Yusuf, Kayode Olayinka, Babalola Adeyemi, Olusegun Ajenifuja, Umar Ibrahim, Yusuf Baffah Adamu, Oluwarotimi Akinola, Grace
Adekola-Oni, Paul Kua, Roseline Iheagwam, Audu Idrisa, Ado Geidam, Andrea Jogo, Joseph Agulebe, Joseph Ikechebelu, Onyebuchi Udegbunam, Jacob Awoleke, Oluseyi Adelekan, Hajaratu Sulayman, Nkeiruka Ameh, Nurudeen Onaolapo, Affiss Adelodun, William Golit, Dachollom Audu, Adetunji Adeniji, Folasade Oyelade, Lamaran
Dattijo, Palmer Henry, Babalola Adeyemi, Olabisi Loto, Odidika Umeora, Abraham Onwe, Emily Nzeribe, Bartthy Okorochukwu, Augustine Adeniyi, Emmanuel Gbejegbe, Akpojaro Ikpen, Ikemefuna Nwosu, Abdulrasaq Sambo, Olubunmi Ladipo, Sola Abubakar, Ola Nene Okike, Enyinnaya Chikwendu Nduka, Eziamaka Pauline Ezenkwele,
Daniel Onwusulu, Theresa Azonima Irinyenikan, Swati Singh, Amaitari Bariweni, Hadiza Galadanci, Peter Achara, Osagie Osayande, Mohammed Gana, Rizwana Chaudhri, Kiran Jabeen, Ayesha Mobeen, Sadaf Mufti, Maliha Zafar, Shehla Noor, Basharat Ahmad, Maimoona Munawar, Jeharat Gul, Naseema Usman, Fehmida Shaheen,
Mariam Tariq, Nadia Sadiq, Rabia Batool, Habiba Sharaf Ali, Manahil Jaffer, Asma Baloch, Noonari Mukhtiar, Tasneem Ashraf, Raheela Asmat, Salma Khudaidad, Ghazala Taj, Roshan Qazi, Saira Dars, Faryal Sardar, Sanobar Ashfaq, Saeeda Majeed, Sadaqat Jabeen, Rukhsana Karim, Farzana Burki, Syeda Rabia Bukhari, Fouzia Gul, Musarrat
Jabeen, Akhtar Sherin, Qurratul Ain, Shahid Rao, Uzma Shaheen, Samina Manzoor, Shabween Masood, Shabana Rizvi, Anita Ali, Abida Sajid, Aisha Iftikhar, Shazia Batool, Lubna Dar, Shahenzad Sohail, Shazia Rasul, Shamsa Humayun, Rashida Sultana, Sofia Manzoor, Syeda Mazhar, Afshan Batool, Asia Nazir, Nasira Tasnim, Hajira
Masood, Razia Khero, Neelam Surhio, Samana Aleem, Naila Israr, Saba Javed, Lubna Bashir, Samina Iqbal, Faiza Aleem, Rubina Sohail, Saima Iqbal, Samina Dojki, Alia Bano, Naseem Saba, Maimoona Hafeez, Nishat Akram, Naila Israr, Riffat Shaheen, Haleema Hashmi, Sharmeen Arshad, Rubina Hussain, Sadia Khan, Nighat Shaheen, Safia
Khalil, Pushpa Sachdev, Gulfareen Arain, Amtullah Zarreen, Sara Saeed, Shamayela Hanif, Nabia Tariq, Mahwish Jamil, Shama Chaudhry, Hina Rajani, Tayyiba Wasim, Summera Aslam, Nilofar Mustafa, Huma Quddusi, Sajila Karim, Shazia Sultana, Misbah Harim, Mohd Chohan, Nabila Salman, Fareesa Waqar, Shamsunnisa Sadia, Lubna
Kahloon, Shehla Manzoor, Samar Amin, Umbreen Akram, Ambreen Ikram, Samina Kausar, Tahira Batool, Brigadier Naila, Tahir Kyani, Christine Biryabarema, Ruth Bulime, Regina Akello, Bernadette Nakawooya Lwasa, Joselyn Ayikoru, Christine Namulwasira, Patrick Komagum, Isabirye Rebecca, Nayiga Annet, Nakirigya Nuulu, Elizabeth
Nionzima, Rose Bwotya, Margret Nankya, Sarah Babirye, Joseph Ngonzi, Cesar Sanchez, Nkonwa Innocent, Kusasira Anitah, Ayiko Jackson, Elizabeth Ndagire, Christine Nanyongo, Dominic Drametu, Grace Meregurwa, Francis Banya, Rita Atim, Emmanuel Byaruhanga, Lema Felix, Hussein Iman, Vincent Oyiengo, Peninah Waigi, Rose
Wangui, Faiza Nassir, Musimbi Soita, Rophina Msengeti, Zeinab Zubier, Hillary Mabeya, Antony Wanjala, Henry Mwangi, Brian Liyayi, Evelyn Muthoka, Alfred Osoti, Amos Otara, Veronicah Ongwae, Zahida Qureshi, Victor Wanjohi, Bonface Musila, Kubasu Wekesa, Alex Nyakundi Bosire, Etienne Asonganyi, Alice Ntem, Angeline
Njoache, Alice Ashu, André Simo, Robert Tchounzou, Dorothy Keka, Kenfack Bruno, Amadou Ndouoya, Martin Saadio, Mesack Tchana, Odel Gwan, Pauline Assomo, Venantius Mutsu, Nji Eric, Pascal Foumane, Philemon Nsem, Jeanne Fouedjio, Ymele Fouelifack, Pierre Marie Tebeu, Georges Nko'ayissi, Eta Ngole Mbong, Wisal Nabag,
Riham Desougi, Hadia Mustafa, Huida Eltaib, Taha Umbeli, Khalid Elfadl, Murwan Ibrahim, Abdalla Mohammed, Awadia Ali, Somia Abdelrahiem, Mohammed Musa, Khidir Awadalla, Samirra Ahmed, Mahdi Bushra, Omer Babiker, Hala Abdullahi, Mohamed Ahmed, Dr. Elhassan Safa, Dr. Huida Almardi, Duria Rayis, Saeed Abdelrahman
Abdelgabar, Zarko Alfirevic, Gillian Houghton, Andrew Sharpe, Jim Thornton, Nick Grace, Carys Smith, Kim Hinshaw, Dawn Edmundson, Paul Ayuk, Alison Bates, George Bugg, Joanne Wilkins, Clare Tower, Alysha Allibone, Eugene Oteng-Ntim, Hussein Kidanto, Ahmad Kazumari, Anna Danford, Matilda Ngarina, Muzdalifat Abeid,
Khadija Mayumba, Magreth Zacharia, George Mtove, Leonard Madame, Anthony Massinde, Berno Mwambe, Rwakyendela Onesmo, Sebastian Kitengile Ganyaka, Mohan Regmi, Shyam Gupta, Rabindra Bhatt, Ajay Agrawal, Pramila Pradhan, Nikita Dhakal, Punita Yadav, Gyanendra Karki, Bhola Ram Shrestha, Bellington Vwalika, Mwansa
Lubeya, Jane Mumba, Willies Silwimba, Isaiah Hansingo, Noojiri Bopili, Ziche Makukula, Alexander Kawimbe, Mwansa Ketty Lubeya, Willard Mtambo, Mathew Ng'ambi, Kastriot Dallaku, Saimir Cenameri, Ilir Tasha, Aferdita Kruja, Besnik Brahimaj, Armida Tola, Leon Kaza, Mateus Sahani, Desire Tshombe, Elizabeth Buligho, Roger
Paluku-Hamuli, Charles Kacha, Kato Faida, Badibanga Musau, Herman Kalyana, Phanny Simisi, Serge Mulyumba, Nzanzu Kikuhe Jason, Jean Robert Lubamba, Willis Missumba, Ferdousi Islam, Nazneen Begum, Sayeba Akhter, Ferdousi Chowdhury, Rokeya Begum, Farjana Basher, Nazlima Nargis, Abu Kholdun, Shahela Jesmin, Shrodha
Paul, Hailemariam Segni, Getachew Ayana, William Haleke, Abdulfetah Abdulkadir, Hassen Hussien, Fikre Geremew, Moussa Bambara, Adolphe Somé, Amadou Ly, Roamba Pabakba, Horace Fletcher, Leslie Samuels, Henry Opare-Addo, Roderick Larsen-Reindorf, Kwadwo Nyarko-Jectey, Glen Mola, Malts Wai, Magdy El Rahman, Wafaa
Basta, Hussein Khamis, Maria Fernanda Escobar, Liliana Vallecilla, Gabriel Essetchi Faye
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
The Lancet
• General medical journal
• Impact factor: 47.831 (2016)
• Editor-in-chief: Richard
Horton
• Headquarters: New York
Published: April 2017
The Lancet 2017 389, 2105-2116DOI:
(10.1016/S0140-6736(17)30638-4)
WORLD MATERNAL
ANTI-FIBRINOLYTIC TRIAL

3. Introduction
Hemorrhage: Most important
cause of maternal mortality
100,000 deaths per year
(WHO - 2015)
Plasminogen
Plasmin
Fibrin Fibrin degradation products
Tranexamic Acid: Anti-Fibrinolytic
TXA
Fibrinolysis increases after childbirth.
Tranexamic acid can greatly reduce PPH,
especially traumatic.

4. Materials and Methods
Study Design:
International,
randomised, double-
blind placebo
Setting: Women with
PPH in 193 hospitals in
21 countries.
Study Group:
20,060 women with
PPH, randomised
to received TXA or
saline placebo.
Duration: March
2010 to April 2016
Clinically estimated blood loss of more than
500 mL after vaginal birth or 1000 mL after
caesarean section or any blood loss sufficient to
compromise haemodynamic stability.
Nigeria, Uganda, Pakistan, UK,
Bangladesh, Ethiopia, Burkina
Faso, Jamaica, Ghana, Egypt,
Colombia, Cote d’Ivoire, Papua
New Guinea, Nepal, Congo,
Albania, Cameroon, Sudan,
Tanzania

5. Flow of Participants

6. Protocol
1 gm of tranexamic acid 1 gm of 0.9% saline
Slow IV, diluted in 100 mL NS, at 1 mL / min
Bleeding after 30 min and within 24 hours?
Post Partum Hemorrhage
Repeat Repeat
Standard protocols
PLUS
PRIMARY OUTCOMES SECONDARY OUTCOMES
• Death from any cause 42 days
post partum
• Hysterectomy
• Amount of bleeding
• Side effects : DVT, stroke, MI, PE
• Need for interventions like tamponade, embolization, arterial ligation,
brace sutures, laparotomy to control bleeding
• Medical complications
• Neonatal side effects

7. Statistical Analysis
Assumed Baseline Rate of Death: 2.5 %
Assumed Rate of Hysterectomy : 2.5 %
Assumed death after hysterectomy: 1%
Original Analysis Plan: Trial of 15,000 women would
have 90% power to detect 25% reduction in death/
hysterectomy (from 4 to 3%) at 5% significance level.
PITFALL: Some clinicians choose to perform hysterectomy
for life threatening bleeding for women enrolled in trial
even before randomisation.
Modified Analysis Plan: Trial of 20,000
women would have 90% power to detect
25% reduction in death/ hysterectomy
(from 3 to 2.25%) at 5% significance level.
This protects against the possibility that the
effect of tranexamic acid on death and
hysterectomy may be different.
All analyses done on intention to treat basis.All effects of treatment were subdivided into three
baseline characteristics:
1. hours from randomisation
2. primary cause of haemorrhage
3. type of birth.
For each binary outcome, risk ratio and 95%
confidence intervals and two sided p-values were
calculated.

8. Characteristics of Participants
Similar baseline characteristics in TXA and placebo groups
1. Age at randomisation (All women above 16 years)
2. Type of Delivery Vaginal (70%) Cesarean (30%)
3. Time between delivery and
randomisation
<1 hour (48%) 1-3 hours (27%) >3 hours (25%)
4. Primary cause of haemorrhage Atony (64%) Previa/ accreta(9%) Trauma/tears (7%)
5. Systolic BP >/-90 mm (80%) <90 mm Hg (20%)
6. Uterotonic prophylaxis given Yes (96%) No/ unknown (4%)
7. Clinical signs of hemodynamic
instability
Yes (59%) No (41%)

9. Primary Outcomes
483 maternal deaths : 77% within
24 hours of randomization and
9% within 1 hour
72% deaths due to bleeding
112 died after
hysterectomy
371 died without
hysterectomy
1. Death due to any cause at <42 days post partum
Summary: Most deaths
occurred within 24 hours, most
due to bleeding

10. Effects of Tranexamic Acid
Significant reduction in
deaths due to bleeding
Death due to other
causes: no significant
difference

11. 82% hysterectomies done for
bleeding
112 died
709 hysterectomies: 86%
within 24 hours and 27%
within 1 hour
597 survived
2. Hysterectomy
Primary Outcomes
351 (3.5%) in
placebo group
The risk of hysterectomy was
not reduced with tranexamic
acid
358 (3.6 %) in
TXA group
(RR 1·02, 95% CI 0·88–1·07; p=0·84).

12. The crucial effect of Timing
TXA given within 3 hours:
Substantially reduced risk of
bleeding
After 3 hours, no risk reduction No heterogeneity in type of delivery
or cause of bleeding

13. Reduction in Surgical InterventionTranexamic acid does not
reduce the need for
interventions like intrauterine
tamponade, MRP,
embolization, brace sutures, or
arterial ligation.
Significant reduction in
laparotomy done for bleeding,
irrespective of vaginal or
cesarean delivery.

14. Other Secondary Outcomes
No significant difference in incidence of thromboembolic events, medical complications, use of
uterotonics, or quality of life.
Thromboembolic events DVT, Pulmonary thromboembolism, MI, stroke
Medical complications Renal failure, cardiac failure, respiratory failure, hepatic failure, sepsis, seizure
Use of uterotonics Oxytocin, Ergometrine, misoprostol, prostaglandin
Quality of life Mobility, pain, discomfort, anxiety, depression

15. Discussion

16. Conclusions of WOMAN Trial
Tranexamic acid reduces
death due to bleeding in
women with PPH by one
third.
Tranexamic acid reduces
laparotomy done to control
bleeding in women with
PPH.
The effect of tranexamic
acid is only when given
within 3 hours of PPH,
more if given earlier than
1 hour.
Tranexamic acid causes no
adverse effects or
complications.

17. 14 million women suffer
from PPH every year. 2 percent of them
die, and many more nearly die but
survive.
Post Partum Hemorrhage

18. Post Partum Hemorrhage
Primary PPH:
Within 24 hours of birth
Secondary PPH:
Between 24 hours and 12 weeks post natal
Minor: 500-1000 mL
Major (Moderate): 1001 -2000 mL
Major (Severe): >2000 mL
Severity of PPH
RCOG Green Top Guideline 52: Dec. 2016
Definition of PPH
Loss of >/-500 mL blood from the genital tract /
causing hemodynamic instability

19. Etiology of PPH
Tone
TraumaThrombin
Tissue
• Multiple Pregnancy
• Previous PPH
• Fetal Macrosomia
• Failure to progress in second stage
• Prolonged third stage
• GA
• Preeclampsia
• Inherited disorders
• DIC
• Retained placenta
• Morbidly adherent placenta
• Episiotomy
• Perineal Laceration
4 T’s
RCOG Green Top Guideline 52: Dec. 2016

20. Problem StatementPPH - leading cause of maternal mortality (34%)
WHO 2015
Incidence of PPH in all pregnancies: 1.2%
Sheldon WR et. al, BJOG: 2014;121(Suppl 1):5–13
M/C Cause: Atony (75%)
Ducloy-Bouthors et. al, Critical Care 2011;15:R177.
Mortality due to PPH
Only 6.5% associated with atony
Other causes: abruption, placenta previa, ruptured uterus, retained placenta,
morbidly adherent placenta, vaginal and cervical trauma, inverted uterus,
bleeding during and after caesarean section
Pattinson RC. Fifth Report on Confidential Enquiries into Maternal Deaths in South Africa 2008-2010.
Pretoria, South Africa: Department of Health, 2012.

21. Review of Literature
Tranexamic acid for the
prophylaxis of PPH
Tranexamic acid for the
treatment of PPH

22. Cochrane Database of Systematic Reviews 2015, Issue 6. Art. No.: CD007872.
12 trials with 3285 healthy
women, low risk of PPH,
both NVD and CS
Uterotonic Prophylaxis PLUS
Placebo/ No intervention Tranexamic Acid
Blood loss greater than 400 mL or 500 mL was less
common in women who received TA versus placebo or no
intervention
Tranexamic
acid for the
prophylaxis
of PPH

23. Trial Setting Participants Intervention Outcomes
Abdel Aleem,
2013
RCT,
Egypt
740 pregnant women >37
weeks , elective LSCS
Intervention group (n=373) - 1 g TXA in 20 mL 5%Dextrose before
LSCS. Control group- routine care
Primary: Mean blood loss during and 2 hours after
LSCS. Secondary: PPH, other interventions needed.
Gai, 2004
RCT, 3
centres,
China
180 primiparas, singletons
undergoing Cesarean
Intervention group (N = 91) - 1 g (10 mL) of TA diluted in 20 mL 5%
glucose given IV 5-10 min before incision. Control (N = 89) - received
routine care.
Blood loss up to 2 hours post partum, PPH, vital
signs, uterine contractility, side effects
Goswami,2013
RCT,
India
90 women, anemic Hb7-10
undergoing cesarean
Control group: 20mL of 5%D, Intervention 1: 10mg/kg TXA in 20mL
dextrose, Intervention 2: 15 mg/kg TXA. Before skin incision
Intraop and post op blood loss, uterine contractiilty,
placental separation, rescue uterotonics needed
Gungorduk, 2011
RCT,
Turkey
Women >38 weeks, elective
CS
Control group: 30 mL5%D 10 min before incision
Intervention: 1 g TXA in 5%D 10 min before incision
Estimated blood loss, PPH, need for additional
uterotonics, need for transfusion, neonatal outcome
Gungordul,2013
RCT,
Turkey
34-42 weeks POG
undergoing vaginal birth
Control group: 30 mL 5% D given at delivery of anterior shoulder
Intervention group: 1gm TXA in 5%D at delivery of anterior shoulder
Estimated blood loss. PPH, need for transfusion,
need for additional uterotonics
Mirghafourvand,
2013
RCT,
Iran
120 women with no risk
factor, vaginal birth
Control group: 200mL NS in 10 min after delivery anterior shoulder
Intervention group: 1 gm TXA in 200 mL NS over 10 min after
delivery of anterior shoulder
Hb and Hct 1-12 hrs before and 12-24 hrs after
delivery. Blood loss, use of additional uterotonics
Movafegh, 2011
RCT,
Iran
100 women for elective CS
Control group: 200 mL normal saline over 10 min, 20 min before SpA
Intervention: 10mg/kg TXA IN 200 mL NS
Blood loss intra op and 2 hours post op, units of
oxytocin, post op Hb, Plt PT and their reduction.
Senturk, 2013
RCT,
Turkey
232 women undergoing CS
(Emergency/ Elective)
Control group: 20mL 5%D 10 minutes before incision
Intervention: 1 gm TXA in 20mL dextrose 10 min before incision
Blood loss, Hb and Hct difference
Shahid, 2013
RCT,
Pakistan
Women at term undergoing
CS
Control group: 20mL 5%D 10 minutes before incision
Intervention: 1 gm TXA in 20mL dextrose 10 min before incision
Vitals, blood loss, uterine contractility, difference in
Hb
Xu, 2013
RCT,
China
176 primipara undergoing
CS by SpA
Control group: 200 mL NS over 10 min prior to skin incision
Intervention: 10 mg/kg TXA in 200 mL saline over 10 min prior
incision
Blood loss, PPH, severe side effects (thrombosis)
and non severe side effects (nausea, phosphenes)
Yang, 2001
RCT,
China
400 primiparous singletons,
vaginal birth
4 groups: I) - TXA 1 g IV (N = 94), 2) - TXA 0.5 g IV (N = 92), 3) -
aminomethylbenzoic acid 0.5 g IV (N = 92), 4) - no treatment (N = 87)
TXA was given IV 2 to 3 minutes after the delivery.
Incidence of PPH, mean blood loss, side effects
Yehia, 2014 RCT 223 women, elective CS
Control: 10 IU oxytocin after delivery of baby
Intervention: 1 gm TA slow IV at induction of anaesthesia
Blood loss, PPH, vitals, need for additional surgical
intervention.

24. Significant risk reduction in both minor and major PPH
Reduction in mean blood loss
Nausea, vomiting, headache,
dizziness, diarrhea, phosphenes
No significant difference in
thromboembolic events

25. Li et al. Medicine (2017) 96:1
25 articles, 4747 participants
Intraoperative, post operative
and total blood loss after CS
and VD with TXA and with
placebo
Effect of TXA on incidence of PPH,
severe PPH, and transfusion needs
CS:
Intraoperative Loss: reduced
by 141.25 mL
Post operative : 36.42 mL
Total: 154.25 mL
VD:
Intraoperative Loss: reduced
by 22.88 mL
Post operative : 41.24 mL
Total: 84.79 mL
Reduced
However, studies not well powered to
draw conclusions
No increased risk of DVT
Minor side effects common
Tranexamic
acid for the
prophylaxis
of PPH

27. Single trial by Ducloy Buthers (2011)
assessing the effect on TXA on PPH
n= 144
Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD003249.
Primary Outcomes
No maternal deaths
No reduction in mean blood loss
No serious maternal morbidity
Secondary Outcomes
No reduction in surgical intervention
Reduction in requirement for blood
transfusion (RR 0.58)
Side Effects
Nausea - RR 11
DVT - 2 cases in TXA group and 1 in
control - RR 2
Inconclusive:
Underpowered trial
WOMAN
Trial : the first large trial
assessing the effect of TXA
for treatment of PPH.
Tranexamic
acid for the
treatment of
PPH

28. Ker et. al, BMJ 2012;344:e3054
Blood Transfusion : TXA
reduces need by one third
Thromboembolic events:
uncertainty about effect
Mortality: Appears to be
reduced by TXA.
However, uncertainty when
analysis restricted to well
concealed trials.

29. Roberts I, Shakur H. Health Technol Assess 2013;17(10)

30. Significant reduction in deaths due to
bleeding, but only if given within 3 hours
No significant difference in vascular
occlusive side effects
The findings of this study led to the
introduction of time stratification in the
WOMAN Trial

31. Practice Guidelines

32. Prevention of PPHUse of uterotonics during third stage labor for all births - universal recommendation
Oxytocin 10 IU (iv/im) - drug of choice
RCOG 2016, WHO 2012
Clinicians should consider
the use of intravenous tranexamic acid (0.5–1.0 g), in
addition to oxytocin, at caesarean section to reduce blood loss in
women at increased risk of PPH.
New RCOG Recommendation 2016, Level A
Alternatives: Ergometrine-Oxytocin,
Misoprostol 600 ug oral
Cochrane Database of Systematic Reviews 2015, Issue 6. Art. No.: CD007872.
Quoted evidence

33. Treatment of PPH
Major Obstetric haemorrhage
Blood loss >1000 mL
Continuing or clinical shock
Call for help
Senior Obstetrician / anaesthetist
Alert haematologist, blood bank
Resuscitation
Airway
Breathing
Circulation
Oxygen Mask (15L)
Fluid balance (e.g.: 2 L isotonic
crystalloid, 1.5 L colloid
Blood transfusion
Blood products (PLT, FFP)
Keep patient warm
Monitoring and Investigations
14 gauge IV canula x 2
CBC, Coagulation, LFT, KFT
Cross match blood
ECG, Oximeter
Foley catheter
Weigh swabs and estimate blood loss
Medical Treatment
Fundal massage
Empty bladder
Oxytocin 5 IU, slow IV, repeat if needed
Ergometrin 0.5 mg slow IV or IM
Oxytocin infusion (40 IU in 500 mL)
Carboprost 0.25 mg IM every 15 minutes up to 8 times
Intramyometrial carboprost 0.5 mg
Misoprostol 800 ug sublingual
CONSIDER TRANEXAMIC ACID 1 GM IV
Theatre
Is the uterus contracted?
Examination under anaesthesia?
Correction of clotting abnormality?
Intrauterine balloon tamponade
Brace suture
Consider interventional radiology
Surgery
Stepwise devascularization
Bilateral internal iliac ligation
Hysterectomy
HDU/ICU
NEW*
2016
RCOG 2016
-Based on extrapolated evidence
from CRASH-2 trial
-Cochrane review by Mousa et. al: “inconclusive”
-WOMAN Trial : cited as being under process

34. WHO 2012:
The use of tranexamic acid is recommended for the treatment of PPH if oxytocin
and other uterotonics fail to stop bleeding or if it is thought that the bleeding
may be partly due to trauma.
(Weak recommendation, moderate-quality evidence - extrapolated from CRASH-2 Trial)
Issued a statement in June 2017 that the
strength of recommendation will be modified
in light of the WOMAN trial.
Treatment of PPH

35. Side effects of TXA
are usually minor with
no significant risk of
thromboembolism.
Take Home Messages
Tranexamic acid can be used
for both prevention and
treatment of post partum
haemorrhage after vaginal
and cesarean delivery.
TXA should be
initiated within 3 hours
and can be repeated as
early as half hour.
TXA reduces
death due to bleeding
by nearly one third and
reduces laparotomy
done for PPH.

36. Thank you