Aboubakr Elnashar

1. Tranexamic acid
for prevention and
treatment of
postpartum
haemorrhage
Prof. Aboubakr
Elnashar
Benha university Hospital, Egypt
ABOUBAKR ELNASHAR

2. CONTENTS
1.PPH
2.TA
3.Treatment
4.Prevention
ABOUBAKR ELNASHAR

3. 1. PPH
Blood loss of more than
500mL following a VD, or
1000mL following a CS.
any blood loss sufficient to compromise
haemodynamic stability.
For normal woman undergoing CS
blood loss of 1000 mL
Common
had a minimal effect on women’s health status.
For woman with severe anemia or CVD undergoing VD
blood loss of as little as 200mL
may be life-threatening
need additional intervention.
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4. Obs hemorrhage:
increased fibrinolytic activity
Placental disruption:
increase in tPA
Increased D-dimer levels postpartum:
increase fibrinolytic activity
Endothelial injury or hypoperfusion secondary to
trauma
Increased tPA
Increased fibrin degradation products
(Pacheco. Obstet Gynecol. 2017)
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5. 2. TA
Potent antifibrinolytic agent=Inhibition of fibrinolysis
blocking lysine binding sites on plasminogen
molecules
Inhibits activation of plasminogen to plasmin.
Inhibits ability of plasmin to form fibrin
degradation productions
Clot breakdown (fibrinolysis) is inhibited and
bleeding is reduced.
(Pacheco. Obstet Gynecol. 2017)
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6. Normally, plasminogen binds with tissue plasminogen activator (tPA) to form plasmin.
This binding degrades fibrin into fibrin degradation products and leads to clot lysis.
TA binds to the lysinebinding site on plasminogen. This new conformation blocks
plasmin binding to fibrin. Fibrin strands are not broken, and a clot persists to slow
bleeding.
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7. Half life: 2 hours
Metabolized by kidney
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8. During delivery, when the placenta separates
physiologic and haemostatic changes occur
sequentially to reduce bleeding:
strong myometrial contractions
increased platelet activity
massive release of coagulation factors: increase
fibrinolytic activity
oxytocin administration:
enhances the first mechanism
TA administration
counter the latter: facilitate the haemostatic process.
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9. Effective and safe in reduce blood loss in
Menorrhagia
Hysterectomy
Myomectomy.
(Naoulou et al[7] Topsoee et al[8] Shaabanet al[9)
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10. Safety
Venous thromboembolic events
seizures and
renal complications
were NOT Seen at higher rates than the controls
±nausea and vomiting
rare but severe adverse neonatal effects may occur
when TA is administered before the cord clamping
since TA is known to cross the placenta.
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11. 3. TA for treatment of PPH
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12. WOMAN trial
20,060 woman with diagnosed PPH enrolled from
193 hospitals in 21 countries
Significant decrease in death due to bleeding
Hysterectomy rates did not change
Death from all causes did not decrease
No increase in adverse outcomes with TXA (ie
VTE)
Effects of early tranexamic acid administration on mortality, hysterectomy, and
other morbidities in women with postpartum hemorrhage (WOMAN): an
international, randomized, double-blind, placebo controlled trial. Lancet May
2017
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13. ABOUBAKR ELNASHAR

14. ABOUBAKR ELNASHAR

15. WHO recommendation, 2017
Early use(within 3 h of birth) of IV TA
in addition to standard care is recommended for
women with clinically diagnosed PPH following
vaginal birth or
CS.
(Strong recommendation, moderate quality of evidence)
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16. Dose:
Fixed dose of 1g (100mg/ml) IV at 1 ml/min
(i.e. administered over 10 min) To Avoid hypotension
Second dose of 1g IV if
bleeding continues after 30 min
bleeding restarts within 24 h of completing the
first dose
Dose not to exceed 2g in 24 h
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17. The reference point for the start of the 3-hour window
for starting TA administration is time of birth.
If time of birth is unknown, the best estimate of time
of birth should be used as the reference point.
As most deaths due to PPH occur within the first 2
to 3 h after birth, it is critical that TA is given as soon
as possible to achieve clinical benefits.
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18. TXA administration beyond 3 h
does not confer any clinical benefit
harm, albeit not statistically significant for women
with PPH.
In view of this evidence, the GDG does not support
the use of TA more than 3 h after birth.
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19. Administration of TA should be considered as part of
the standard PPH treatment.
fluid replacement
medical (uterotonics)
monitoring of vital signs
Nonsurgical
bimanual compression
intrauterine balloon tamponade
nonpneumatic antishock garment
aortic compression
surgical interventions
brace sutures
arterial ligation, or
Hysterectomy
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20. TA should be used in all cases of PPH
regardless of whether the bleeding is due to genital
tract trauma or other causes.
The use of TA should be avoided in
clear contraindication to antifibrinolytic therapy
known thromboembolic event during pregnancy
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21. This recommendation applies only to IV use.
The evaluation of benefits and potential harms of
other routes of TA administration is a research priority.
TA should be recognized as a life-saving intervention
and be made readily available for the management of
PPH in settings where emergency obstetric care is
provided.
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22. Cochrane SR, 2018
IV TA reduces mortality due to bleeding in women
with primary PPH
irrespective of mode of birth
without increasing the risk of thromboembolic events
TA is effective if given as early as possible.
alternative routes to IV administration need to be
investigated
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23. 4. TA for prevention
Cochrane Syst Rev. 2015
12 trials
3285 healthy women at low risk of excessive
bleeding undergoing
elective CS (9 trials, 2453 participants) or
spontaneous birth (3 trials, 832 participants)
Routine prophylactic uterotonics in addition to TA or
placebo or no intervention.
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24. TA vs placebo or no intervention:
Blood loss greater than 400 mL or 500 mL, and
more than 1000 mL was less
Mean blood loss (from delivery until 2h
postpartum) was lower
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25. TA (in addition to uterotonic medications) decreases
postpartum blood loss and prevents PPH and blood
transfusions following vaginal birth and CS
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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26. Li et al, 2017 SR
25 articles
4747 participants
TA
reduced intra-, postoperative, and total blood loss
by a mean volume of 141.25 mL, 36.42 mL, and
154.25 mL in CS.
in VD was associated with a reduced intra-,
postoperative, and total blood loss by a mean
volume of 22.88 mL, 41.24 mL, and 84.79 mL
lower the occurrence rate of PPH and severe
PPH, and reduce risk of blood transfusions.
No increased risk of DVT
minor side effects were more common
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27. IV TA for patients undergoing CS was
effective and safe
Although prophylactic TA administration is
associated with reduced PPH, current existing data
are insufficient to draw definitive recommendations
about its clinical significance due to the poor to
moderate quality of the included literatures
high-quality RCT with larger samples are needed to
validate our findings.
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28. Thanks
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