Joint Statement of Recommendation for the Use of Tranexamic Acid for the Treatment of Postpartum Haemorrhage

Postpartum haemorrhage (PPH) is a devastating but preventable condition that affects mothers and their children around the world. PPH occurs when a mother has serious bleeding after giving birth. When not treated quickly, it can be fatal. Most deaths from PPH could be avoided through active management of the third stage of labour, and prompt and effective application of the first response bundle (use of uterotonics, uterine massage, fluid replacement and tranexamic acid [TXA]). 

Preventing and treating PPH

As leading organisations representing specialists in midwifery, obstetrics and gynaecology, the International Federation of Gynaecology and Obstetrics (FIGO) and the International Confederation of Midwives (ICM) draw attention to a range of aspects of care that are essential to the prevention and treatment of PPH. These include:

• organisation of care
• pre-service and in-service training of care providers
• identification and treatment of anaemia in women of childbearing age
• increased availability of contraception and family planning
• improved referral pathways
• development of clinical protocols for prevention and treatment of PPH.[1]

FIGO and ICM recommendations

FIGO and ICM recommend the early use of TXA within three hours of birth, in addition to standard care for women with clinically diagnosed PPH following vaginal birth or caesarean section.

Standard care in the context of this recommendation covers routine care for PPH, including fluid replacement, administration of uterotonics, monitoring of vital signs, non-surgical (e.g. bimanual compression, intrauterine balloon tamponade, nonpneumatic antishock garment, aortic compression) and surgical interventions (e.g. brace sutures, arterial ligation, or hysterectomy) in accordance with WHO guidelines, FIGO recommendations or adapted local PPH treatment protocols.

TXA is a competitive inhibitor of plasminogen activation. It can reduce bleeding by inhibiting the enzymatic breakdown of fibrinogen and fibrin clots. TXA is in routine clinical use for reduction of blood loss in surgery and trauma and is listed on the WHO Essential Medicines List for management of postpartum haemorrhage.

Use of tranexamic acid for the treatment of PPH

FIGO and ICM strongly recommend the use of TXA for the treatment of PPH as a component of the first response bundle when the bleeding is thought to be due or partly due to trauma. Our recommendations (below) align with those made in the WHO 2017 recommendation on tranexamic acid for the treatment of postpartum haemorrhage, in response to moderate supporting evidence from the WOMAN Trial.1,2,3

• Initial dose of TXA should be administered within 3 hours of birth, at a fixed dose of 1g (100mg/ml), IV at 1ml per minute (i.e. administered over 10–20 minutes). Infusion rate of more than 1ml/minute can cause hypotension.
• Initial administration of TXA beyond 3 hours does not confer any clinical benefit.
• If needed after initial dose, a second dose of TXA of 1g (100mg/ml), IV at 1ml per minute should be administered if bleeding continues after 30 minutes, or if bleeding restarts within
• 24 hours of completing the first dose.
• TXA should be used in all cases of PPH regardless of whether the bleeding is due to genital tract trauma or other causes.
• Use of TXA should be avoided in women with a contraindication to antifibrinolytic therapy or thromboembolic disorder during pregnancy.
• Standard IV infusion equipment is required, as well as health care providers with sufficient training to safely administer IV bolus infusions.
• TXA should be recognised as a life-saving intervention and be made readily available for the management of PPH in settings where emergency obstetric care is provided.

Actions for midwives’ associations and OBGYN societies

FIGO and ICM recommend that national professional midwives’ associations and obstetrics and gynaecology societies have an important and collaborative role to play in:

• the dissemination and implementation of recommendations for the use of tranexamic acid for the treatment of PPH
• advocacy to increase women’s access to quality maternal health care at all levels
• strengthening capacity at all levels of health care facilities to ensure the provision of
• high-quality services to all women giving birth
• translating recommendations into care packages and programmes at country and facility level, where appropriate to the context.

References

1. World Health Organization. WHO recommendation for the prevention and treatment of postpartum haemorrhage. 2012.
2. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage: an international, randomised, double-blind, placebo-controlled trial. The Lancet. 389(10084):2105-2116.
3. World Health Organization. WHO recommendation on tranexamic acid for the treatment of postpartum haemorrhage. 2017.