Advertisement

Tranexamic acid for the prevention of postpartum hemorrhage in women undergoing cesarean delivery: an updated meta-analysis

Published:September 25, 2021DOI:https://doi.org/10.1016/j.ajog.2021.09.025

      Objective

      This study aimed to assess the efficacy and safety of prophylactic tranexamic acid administration vs standard uterotonic agents alone among women undergoing cesarean delivery.

      Data Sources

      MEDLINE, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and Google Scholar were systematically searched from inception to June 30, 2021.

      Study Eligibility Criteria

      Randomized controlled trials comparing intravenous tranexamic acid administration with placebo in women undergoing cesarean delivery and receiving standard prophylactic uterotonic agents were held eligible.

      Study Appraisal and Synthesis Methods

      The risk of bias of individual studies was appraised with the Risk of Bias 2 tool. Meta-analysis was conducted by fitting random-effects models using restricted maximum likelihood. Subgroup analysis was performed on the basis of country, protocol availability, double-blinding, risk of bias, sample size, and tranexamic acid dose. A 1-stage meta-analysis was performed as a sensitivity analysis. The credibility of outcomes was appraised with the Grading of Recommendations Assessment, Development and Evaluation approach.

      Results

      Overall, 36 studies with 10,659 women were included. Tranexamic acid administration was associated with significantly lower total blood loss (mean difference, −189.44 mL; 95% confidence intervals, −218.63 to −160.25), lower hemoglobin drop (mean difference, 8.22%; 95% confidence interval, 5.54–10.90), decreased risk of blood loss of >1000 mL (odds ratio, 0.37; 95% confidence interval, 0.22–0.60), transfusion requirement (odds ratio, 0.41; 95% confidence interval, 0.26–0.65), and need of additional uterotonics (odds ratio, 0.36; 95% confidence interval, 0.25–0.52). Subgroup analysis indicated a greater effect of tranexamic acid on total blood loss reduction in low-middle income countries. The outcomes remained stable by separately evaluating women at low bleeding risk. The 1-stage meta-analysis demonstrated similar outcomes with the primary analysis. The quality of evidence was judged to be moderate regarding total blood loss and hemoglobin percentage change and low for the other outcomes.

      Conclusion

      This meta-analysis suggested that prophylactic tranexamic acid administration is effective among women undergoing cesarean delivery in lowering postpartum blood loss and limiting hemoglobin drop. Further research is needed to test its efficacy in high-risk populations and verify its safety profile.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Miller S.
        • Lester F.
        • Hensleigh P.
        Prevention and treatment of postpartum hemorrhage: new advances for low-resource settings.
        J Midwifery Womens Health. 2004; 49: 283-292
        • Oyelese Y.
        • Ananth C.V.
        Postpartum hemorrhage: epidemiology, risk factors, and causes.
        Clin Obstet Gynecol. 2010; 53: 147-156
        • Borovac-Pinheiro A.
        • Pacagnella R.C.
        • Cecatti J.G.
        • et al.
        Postpartum hemorrhage: new insights for definition and diagnosis.
        Am J Obstet Gynecol. 2018; 219: 162-168
        • Neary C.
        • Naheed S.
        • McLernon D.J.
        • Black M.
        Predicting risk of postpartum haemorrhage: a systematic review.
        BJOG. 2021; 128: 46-53
        • Anderson J.M.
        • Etches D.
        Prevention and management of postpartum haemorrhage: Green-top Guideline No. 52.
        BJOG. 2017; 124: e106-e149
        • Cai J.
        • Ribkoff J.
        • Olson S.
        • et al.
        The many roles of tranexamic acid: an overview of the clinical indications for TXA in medical and surgical patients.
        Eur J Haematol. 2020; 104: 79-87
        • Al-Jeabory M.
        • Szarpak L.
        • Attila K.
        • et al.
        Efficacy and safety of tranexamic acid in emergency trauma: a systematic review and meta-analysis.
        J Clin Med. 2021; 10: 1030
        • Yu Z.
        • Ling L.
        Tranexamic acid in intracerebral hemorrhage: a meta-analysis.
        Int J Neurosci. 2021; ([Epub ahead of print])
        • Koh A.
        • Adiamah A.
        • Gomez D.
        • Sanyal S.
        Safety and efficacy of tranexamic acid in minimizing perioperative bleeding in extrahepatic abdominal surgery: meta-analysis.
        BJS Open. 2021; 5: zrab004
        • Hartland A.W.
        • Teoh K.H.
        • Rashid M.S.
        Clinical effectiveness of intraoperative tranexamic acid use in shoulder surgery: a systematic review and meta-analysis.
        Am J Sports Med. 2021; 49: 3145-3154
        • Shakur H.
        • Roberts I.
        • Fawole B.
        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.
        Lancet. 2017; 389: 2105-2116
        • Gayet-Ageron A.
        • Prieto-Merino D.
        • Ker K.
        • et al.
        Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40138bleeding patients.
        Lancet. 2018; 391: 125-132
        • Novikova N.
        • Hofmeyr G.J.
        • Cluver C.
        Tranexamic acid for preventing postpartum haemorrhage.
        Cochrane Database Syst Rev. 2015; 6: CD007872
        • Li C.
        • Gong Y.
        • Dong L.
        • Xie B.
        • Dai Z.
        Is prophylactic tranexamic acid administration effective and safe for postpartum hemorrhage prevention? A systematic review and meta-analysis.
        Medicine (Baltimore). 2017; 96: e5653
        • Wang Y.
        • Liu S.
        • He L.
        Prophylactic use of tranexamic acid reduces blood loss and transfusion requirements in patients undergoing cesarean section: a meta-analysis.
        J Obstet Gynaecol Res. 2019; 45: 1562-1575
        • Sentilhes L.
        • Daniel V.
        • Deneux-Tharaux C.
        TRAAP2 Study Group and the Groupe de Recherche en Obstétrique et Gynécologie (GROG). TRAAP2—Tranexamic acid for preventing postpartum hemorrhage after cesarean delivery: a multicenter randomized, doubleblind, placebo- controlled trial—a study protocol.
        BMC Preg Childbirth. 2020; 20: 63
        • Page M.J.
        • McKenzie J.E.
        • Bossuyt P.M.
        • et al.
        The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.
        BMJ. 2021; : 372
        • Sterne J.A.C.
        • Savović J.
        • Page M.J.
        • et al.
        RoB 2: a revised tool for assessing risk of bias in randomised trials.
        BMJ. 2019; 366: l4898
        • Higgins J.P.T.
        • Thompson S.G.
        • Deeks J.J.
        • Altman D.G.
        Measuring inconsistency in meta-analyses.
        BMJ. 2003; 327: 557-560
        • IntHout J.
        • Ioannidis J.P.A.
        • Rovers M.M.
        • Goeman J.J.
        Plea for routinely presenting prediction intervals in meta-analysis.
        BMJ Open. 2016; 6: e010247
        • Haney E.M.
        • Huffman L.H.
        • Bougatsos C.
        • et al.
        Appendix 6. Statistical methods used for meta analysis.
        (Available at:)
        https://www.ncbi.nlm.nih.gov/books/NBK33484/
        Date: 2007
        Date accessed: April 22, 2021
        • Leimu R.
        • Koricheva J.
        Cumulative meta-analysis: a new tool for detection of temporal trends and publication bias in ecology.
        Proc Biol Sci. 2004; 271: 1961-1966
        • Jackson D.
        • White I.R.
        When should meta-analysis avoid making hidden normality assumptions?.
        Biom J. 2018; 60: 1040-1058
        • Jackson D.
        • Law M.
        • Stijnen T.
        • Viechtbauer W.
        • White I.R.
        A comparison of seven random-effects models for meta-analyses that estimate the summary odds ratio.
        Stat Med. 2018; 37: 1059-1085
        • Papadimitropoulou K.
        • Stijnen T.
        • Dekkers O.M.
        • Cessie S le
        One-stage random effects meta-analysis using linear mixed models for aggregate continuous outcome data.
        Res Synth Methods. 2019; 10: 360-375
        • Guyatt G.
        • Oxman A.D.
        • Akl E.A.
        • et al.
        GRADE guidelines: 1. Introduction—GRADE evidence profiles and summary of findings tables.
        J Clin Epidemiol. 2011; 64: 383-394
        • Sherafati G.
        • Akhlaghi F.
        • Mostafa K.
        Assessment of the effects of tranexamic acid (TXA) in reducing bleeding loss during and after cesarean section (CS).
        Adv Biolres. 2017; 8: 121-124
        • Sampathkumari S.
        • Arulmozhi M.
        • Priya R.
        • Mahalakshmi V.
        A study on efficacy of prophylactic tranexamic acid in reducing blood loss during elective Lscs.
        IOSR J Dent Med Sci. 2018; 17: 59-63
        • Taj N.
        • Firdous A.
        • Akhtar N.
        • et al.
        Efficacy of tranexamic acid in reducing blood loss during and after cesarean section.
        Rawal Med J. 2014; 39: 311-313
        • Malathi P.
        • Anupama D.
        • Habitha P.
        Effect of injection tranexamic acid on perioperative blood loss during cesarean section.
        Int Arch Integr Med. 2016; 3: 280-289
        • Thavare M.G.
        • Patil A.S.
        To study the effect of intravenous tranexamic acid on blood loss during and after caesarean section.
        MVP Journal of Medical Sciences. 2019; 6: 93-99
        • Nayyef S.S.
        • Darweesh M.R.
        • Ibraheem A.F.
        The effect of routine intraoperative tranexamic acid in elective cesarean section.
        Int J Adv Res Med. 2020; 2: 85-90
        • Shalabi Y.L.M.
        • Mohammad S.Z.
        Efficacy of intravenous tranexamic acid in reducing blood loss during and after elective cesarean section.
        Sci J Al-Azhar Med Fac Girls. 2020; 4: 600
        • Mayur G.
        • Purvi P.
        • Ashoo G.
        • Pankaj D.
        Efficacy of tranexamic acid in decreasing blood loss during and after cesarean section: a randomized case controlled prospective study.
        J Obstet Gynecol India. 2007; 57: 227-230
        • Singh T.
        • Burute S.B.
        • Deshpande H.G.
        • Jethani S.
        • Ratwani K.
        Efficacy of tranexamic acid in decreasing blood loss during and after caesarean section: a randomized case control prospective study.
        J Evol Med Dent Sci. 2014; 3: 2780-2788
        • Sekhavat L.
        • Tabatabaii A.
        • Dalili M.
        • Farajkhoda T.
        • Tafti A.D.
        Efficacy of tranexamic acid in reducing blood loss after cesarean section.
        J Matern Fetal Neonatal Med. 2009; 22: 72-75
        • Rushulo K.
        • Ranjit S.L.
        • Rameswar S.M.
        Effect of intravenous administration of tranexamic acid in reducing blood loss during and after caesarean section.
        (Available at:) (Accessed June 25, 2021)
        • Abbas Q.
        • Latif F.
        Frequency of postpartum haemorrhage with intravenous tranexamic acid versus placebo in females undergoing caesarean section at term.
        (Available at:)
        • Acharya S.
        • Mishra S.
        Efficacy of tranexamic acid in reducing blood loss in cesarean section: a comparative study.
        J Lumbini Med Coll. 2019; 7: 44-49
        • Al-Garhy E.T.
        • Mohamed A.H.
        • Barakat I.A.
        Effect of tranexamic acid on blood loss in elective cesarean delivery.
        Egypt J Hosp Med. 2019; 74: 1314-1321
        • Ibrahim T.H.
        Efficacy of tranexamic acid in reducing blood loss, blood and blood products requirements in cesarean sections for patients with placenta accreta.
        Ain-Shams J Anesthesiol. 2019; 11: 1-6
        • Sahhaf F.
        • Abbasalizadeh S.
        • Ghojazadeh M.
        • et al.
        Comparison effect of intravenous tranexamic acid and misoprostol for postpartum haemorrhage.
        Niger Med J. 2014; 55: 348-353
        • Mohamed M.
        • EL-Boghdady A.
        • Hegazy E.G.F.
        Efficacy intravenous tranexamic acid in reducing blood loss after elective cesarean sections.
        Med J Cairo Univ. 2018; 86: 3607-3615
        • Pakniat H.
        • Chegini V.
        • Shojaei A.
        • Khezri M.B.
        • Ansari I.
        Comparison of the effect of intravenous tranexamic acid and sublingual misoprostol on reducing bleeding after cesarean section: a double-blind randomized clinical trial.
        J Obstet Gynecol India. 2018; 69: 239-245
        • Roy I.
        • Chakraborty S.
        • Mukhopadhyay S.
        Role of intravenous tranexamic acid on cesarean blood loss: a prospective randomized study.
        Trop J Obstet Gynaecol. 2018; 35: 49-53
        • Chattopadhyay S.
        • Sarkar S.
        • Chakrabarti S.
        • Mandal M.
        Effect of intravenous tranexamic acid administration on blood loss during and after elective caesarean delivery—a randomised placebo-controlled study.
        J Evol Med Dent Sci. 2017; 6: 1286-1292
        • Ali S.A.A.
        • Oof T.F.
        • Elmolla M.F.
        Efficacy of intravenous tranexamic acid in reducing blood loss after elective cesarean section.
        Egypt J Hosp Med. 2019; 74: 1353-1358
        • Maree F.S.
        • Hassein M.R.
        Comparison between the effect of using of oxytocin and oxytocin with tranexamic acid in reducing uterine bleeding during and after caesarean section.
        Ann Trop Med Public Health. 2020; 23: SP23935
        • Kafayat H.
        • Janjua M.
        • Naheed I.
        • Iqbal T.
        To assess the prophylactic role of tranexamic acid in reducing blood loss during and after two hours of caesarean section.
        Pakistan J Medical Health Sci. 2018; 12: 1662-1665
        • Alanwar A.
        • Gamal M.M.
        • Alanwar A.
        • Gamal M.M.
        Tranexamic acid and ethamsylate for reducing blood loss in patient undergoing lower segment Cesarean section at high risk for post-partum hemorrhage: a pilot study.
        Open J Obstet Gynecol. 2020; 10: 1340-1350
        • Milani F.
        • Haryalchi K.
        • Sharami S.H.
        • Atrkarroshan Z.
        • Farzadi S.
        Prophylactic effect of tranexamic acid on hemorrhage during and after the cesarean section.
        Aras Part Med Int Press. 2019; 7: 74-78
        • Elden Kamel H.H.
        • Farhan A.M.
        • Abou Senna H.F.
        • Khedr M.A.
        • Albhairy A.A.
        Role of prophylactic tranexamic acid in reducing blood loss during elective caesarean section in rural area.
        Egypt J Hosp Med. 2018; 73: QC17-QC21
        • Ahmed M.R.
        • Ahmed W.A.S.
        • Madny E.H.
        • Arafa A.M.
        • Said M.M.
        Efficacy of tranexamic acid in decreasing blood loss in elective caesarean delivery.
        J Matern Fetal Neonatal Med. 2015; 28: 1014-1018
        • Xu J.
        • Gao W.
        • Ju Y.
        Tranexamic acid for the prevention of postpartum hemorrhage after cesarean section: a double-blind randomization trial.
        Arch Gynecol Obstet. 2012; 287: 463-468
        • Shahid A.
        • Khan A.
        Tranexamic acid in decreasing blood loss during and after caesarean section.
        J Coll Physicians Surg Pak. 2013; 23: 459-462
        • Sentürk M.B.
        • Cakmak Y.
        • Yildiz G.
        • Yildiz P.
        Tranexamic acid for cesarean section: a double-blind, placebo-controlled, randomized clinical trial.
        Arch Gynecol Obstet. 2012; 287: 641-645
        • Goswami U.
        • Sarangi S.
        • Gupta S.
        • Babbar S.
        Comparative evaluation of two doses of tranexamic acid used prophylactically in anemic parturients for lower segment cesarean section: a double-blind randomized case control prospective trial.
        Saudi J Anaesth. 2013; 7: 427-431
        • Movafegh A.
        • Eslamian L.
        • Dorabadi A.
        Effect of intravenous tranexamic acid administration on blood loss during and after cesarean delivery.
        Int J Gynaecol Obstet. 2011; 115: 224-226
        • Gungorduk K.
        • Yıldırım G.
        • Asıcıoğlu O.
        • Gungorduk O.C.
        • Sudolmus S.
        • Ark C.
        Efficacy of intravenous tranexamic acid in reducing blood loss after elective cesarean section: a prospective, randomized, double-blind, placebo-controlled study.
        Am J Perinatol. 2011; 28: 233-240
        • Sharma R.
        • Najam R.
        • Misra M.K.
        Efficacy of tranexamic acid in decreasing blood loss during and after cesarean section.
        (Available at:)
        • Gai M.Y.
        • Wu L.F.
        • Su Q.F.
        • Tatsumoto K.
        Clinical observation of blood loss reduced by tranexamic acid during and after caesarian section: a multi-center, randomized trial.
        Eur J Obstet Gynecol Reprod Biol. 2004; 112: 154-157
        • Abd El-Gaber A.E.-N.A.
        • Ahmed H.H.
        • Khodry M.M.
        • Abbas A.M.
        Effect of tranexamic acid in prevention of postpartum hemorrhage in elective caesarean delivery: a randomized controlled study.
        Int J Reprod Contracept Obstet Gynecol. 2018; 8: 1-5
        • Sujata N.
        • Tobin R.
        • Kaur R.
        • Aneja A.
        • Khanna M.
        • Hanjoora V.M.
        Randomized controlled trial of tranexamic acid among parturients at increased risk for postpartum hemorrhage undergoing cesarean delivery.
        Int J Gynaecol Obstet. 2016; 133: 312-315
        • Nargis N.
        • Dewan F.
        Prophylactic use of tranexamic acid during caesarean section in preventing postpartum haemorrhage—a prospective randomised double blind placebo controlled study.
        Bangladesh J Obstet Gynaecol. 2018; 33: 125-130
        • El-Sttar M.
        • El-Gayed A.
        • Dawood R.
        • El-Sayd Ghnnam Y.
        Misoprostol and tranexamic acid role in reducing blood loss during the elective cesarean section.
        Menoufia Med J. 2019; 32: 465-469
        • Ifunanya N.J.
        • Chukwu I.C.
        • Nobert O.C.
        • Blessing O.
        • Chibuzor U.D.
        • Uchenna O.V.
        Tranexamic acid versus placebo for prevention of primary postpartum haemorrhage among high risk women undergoing caesarean section in Abakaliki: a randomized controlled trial.
        Open J Obstet Gynecol. 2019; 09: 914-922
        • Shabir N.
        • Pirzada H.
        • Hanif S.
        • Rafique R.
        Tranexamic acid and blood loss during and after cesarean section: a prospective randomized study.
        (Available at:)
        • Obi V.
        • Umeora O.
        • Dimejesi I.
        • et al.
        Efficacy of intravenous tranexamic acid at reducing blood loss during elective caesarean section in Abakaliki: a double blind randomized placebo controlled trial.
        Afr J Med Heal Sci. 2019; 18: 10-17
        • Sanad Z.
        • Ellakwa H.E.
        • Gomaa A.M.
        • Hamza H.A.
        • Elsalamony H.H.
        Effect of tranexamic acid in reducing blood loss during and after cesarean delivery.
        Menoufia Med J. 2020; 33: 1275
        • Hemapriya L.
        • More G.
        • Kumar A.
        Efficacy of tranexamic acid in reducing blood loss in lower segment cesearean section: a randomised controlled study.
        J Obstet Gynaecol India. 2020; 70: 479-484
        • Adel Nour D.
        • El Husseiny T.
        • Osman N.
        Efficacy and safety of preoperative intravenous tranexamic acid to reduce blood loss during and after elective lower-segment cesarean delivery.
        Evid Based Womens Heal J. 2021; 11: 177-181
        • Torky H.
        • El-Desouky E.S.
        • Abo-Elmagd I.
        • et al.
        Pre-operative tranexemic acid vs. etamsylate in reducing blood loss during elective cesarean section: randomized controlled trial.
        J Perinat Med. 2021; 49: 353-356
        • Soliman A.A.
        • Mahmoud S.A.
        • Dawood R.M.
        • Fayed A.A.
        • Fathey A.A.
        Prophylactic use of tranexamic acid in reducing blood loss during elective cesarean section.
        Egypt J Hosp Med. 2021; 82: 6-10
        • Ray I.
        • Bhattacharya R.
        • Chakraborty S.
        • Bagchi C.
        • Mukhopadhyay S.
        Role of intravenous tranexamic acid on caesarean blood loss: a prospective randomised study.
        J Obstet Gynaecol India. 2016; 66: 347-352
        • Sentilhes L.
        • Sénat M.V.
        • Le Lous M.
        • et al.
        Tranexamic acid for the prevention of blood loss after cesarean delivery.
        N Engl J Med. 2021; 384: 1623-1634
        • Naeiji Z.
        • Delshadiyan N.
        • Saleh S.
        • Moridi A.
        • Rahmati N.
        • Fathi M.
        Prophylactic use of tranexamic acid for decreasing the blood loss in elective cesarean section: a placebo-controlled randomized clinical trial.
        J Gynecol Obstet Hum Reprod. 2021; 50: 101973
        • Jafarbegloo E.
        • Faridnyia F.
        • Ahangari R.
        • et al.
        Prophylactic use of tranexamic acid on blood loss in cesarean delivery: a randomized controlled- clinical trial.
        Trauma Mon. 2021; 26: 19-24
        • Fahmy N.G.
        • Eskandar F.S.L.
        • Khalil W.A.M.A.
        • Sobhy M.I.I.
        • Amin A.M.A.A.
        Assessment the role of tranexamic acid in prevention of postpartum hemorrhage.
        Ain-Shams J Anesthesiol. 2021; 13: 1-8
        • Tabatabaie S.S.
        • Alavi A.
        • Bazaz M.
        Comparison of the effect of tranexamic acid and misoprostol on blood loss during and after cesarean section: a randomized clinical trial.
        Razavi Int J Med. 2021; 9: 7-13
        • Halifa I.S.
        • Oluwasola T.A.O.
        • Fawole B.
        • Oladokun A.
        Intravenous tranexamic acid for reducing blood loss during cesarean delivery: a double-blind, randomized-controlled trial.
        N Niger J Clin Res. 2021; 10: 40-46
        • Lakshmi S.D.
        • Abraham R.
        Role of prophylactic tranexamic acid in reducing blood loss during elective caesarean section: a randomized controlled study.
        J Clin Diagn Res. 2016; 10: QC17-QC21
        • Bhavana G.
        • Abhishek M.
        • Suneeta M.
        Efficacy of prophylactic tranexamic acid in reducing blood loss during and after caesarean section.
        Int J Reprod Contracept Obstet Gynecol. 2017; 5: 2011-2016
        • Abdel-Aleem H.
        • Alhusaini T.K.
        • Abdel-Aleem M.A.
        • Menoufy M.
        • Gülmezoglu A.M.
        Effectiveness of tranexamic acid on blood loss in patients undergoing elective cesarean section: randomized clinical trial.
        J Matern Fetal Neonatal Med. 2013; 26: 1705-1709
        • Maged A.M.
        • Helal O.M.
        • Elsherbini M.M.
        • et al.
        A randomized placebo-controlled trial of preoperative tranexamic acid among women undergoing elective cesarean delivery.
        Int J Gynaecol Obstet. 2015; 131: 265-268
        • Yehia A.H.
        • Koleib M.H.
        • Abdelazim I.A.
        • Atik A.
        Tranexamic acid reduces blood loss during and after cesarean section: a double blinded, randomized, controlled trial.
        Asian Pac J Reprod. 2014; 3: 53-56
        • Ghosh A.
        • Chaudhuri P.
        • Muhuri B.
        Efficacy of intravenous tranexamic acid before cesarean section in preventing post partum hemorrhage–—a prospective randomised double blind placebo controlled study.
        Int J Biol Med Res. 2014; 5: 4461-4464
        • Ahmadzia H.K.
        • Luban N.L.C.
        • Li S.
        • et al.
        Optimal use of intravenous tranexamic acid for hemorrhage prevention in pregnant women.
        Am J Obstet Gynecol. 2021; 225: 85.e1-85.e11
        • Knight M.
        • Callaghan W.M.
        • Berg C.
        • et al.
        Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group.
        BMC Preg Childbirth. 2009; 91: 1-10
        • Durand-Zaleski I.
        • Deneux-Tharaux C.
        • Seco A.
        • et al.
        An economic evaluation of tranexamic acid to prevent postpartum haemorrhage in women with vaginal delivery: the randomised controlled TRAAP trial.
        BJOG. 2021; 128: 114-120
        • Sudhof L.S.
        • Shainker S.A.
        • Einerson B.D.
        Tranexamic acid in the routine treatment of postpartum hemorrhage in the United States: a cost-effectiveness analysis.
        Am J Obstet Gynecol. 2019; 221 (275.e1–212)
        • University Hospital of Bordeaux
        Tranexamic acid for preventing blood loss following a cesarean delivery in women with placenta pREVIA. NCT04304625.
        (Available at:)
        • Arribas M.
        • Roberts I.
        • Chaudhri R.
        • et al.
        WOMAN-PharmacoTXA trial: study protocol for a randomised controlled trial to assess the pharmacokinetics and pharmacodynamics of intramuscular, intravenous and oral administration of tranexamic acid in women giving birth by caesarean section.
        Wellcome Open Res. 2021; 6: 157

      Linked Article

      • Tranexamic acid for the prevention of postpartum hemorrhage in women undergoing cesarean delivery
        American Journal of Obstetrics & GynecologyVol. 226Issue 5
        • Preview
          We read with interest the meta-analysis performed by Bellos and Pergialotis.1 The authors included 36 randomized controlled trials involving 10,659 women. The authors judged that none of the included trials were at a high risk of bias, with 21 (58.3%) trials judged to be at a low risk and 15 (41.7%) trials to be at a moderate risk of bias; the remainder were rated as unclear. The fact that no trials were judged to be at a high risk of bias was included as a strength of the meta-analysis and apparently informed the conclusions.
        • Full-Text
        • PDF
      • Reply: Prophylactic tranexamic acid in cesarean delivery: synthesis of evidence
        American Journal of Obstetrics & GynecologyVol. 226Issue 5
        • Preview
          We would like to thank Sentilhes et al1 for their interest in our meta-analysis evaluating the effects of prophylactic tranexamic acid in the prevention of postpartum hemorrhage in women undergoing cesarean delivery.2 Concerns were mainly raised regarding the quality of the included studies except for the Tranexamic Acid for Preventing Postpartum Hemorrhage Following a Cesarean Delivery (TRAAP2) trial. However, the meta-analysis systematically accumulated current literature evidence, by applying strict inclusion criteria.
        • Full-Text
        • PDF