By James Heilman, MD – Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=56596333
Pearl: TXA can be used for post-partum hemorrhage. Its utility for other forms of gynecologic bleeding is unclear.
Background: TXA (Tranexamic Acid) now has an established role in controlling the hemorrhagic shock of a trauma patient after the CRASH-2 trial. I recently cared for a patient who presented in acute distress with a vaginal (uterine) bleed, an INR of 3.7 (hepatic coagulopathy) and a hgb of 2.5 mg/dl. Having heard that TXA may be applicable to uterine bleeding, I administered it in tandem with the MTP. Now I want to know if there is evidence supporting that decision.
Evidence: A review article in Obstetrics and Gynecology (an ACOG Publication) by Pacheco et al described multiple recent RCTs and a Cochrane review of the two major peripartum applications for TXA: Prophylactic administration prior to C-section and post-partum administration (in tandem with oxytocin) for hemorrhage. There appears to be good evidence for reduction of patient centered negative outcomes (i.e. death from hemorrhage), especially when given within 3 hours of hemorrhage onset (in parallel to the trauma literature). There is no evidence of increases in pro-thrombotic events.
Bottom Line: Though the evidence does support the use of TXA in a hemorrhaging post-partum woman (along with oxytocin), the time window appears to matter (under 3 hours). There is not adequate data to support its use for uterine bleeding which has been ongoing for a longer period of time prior to presentation (as in my patient). However, given its overall safety profile, it may be reasonable to use it as a single dose in acutely life threatening non-traumatic hemorrhage scenarios where any potential benefit would be of value.
(1) Pacheco LD1, Hankins GDV, Saad AF, Costantine MM, Chiossi G, Saade GR. Tranexamic Acid for the Management of Obstetric Hemorrhage. Obstet Gynecol. 2017 Oct;130(4):765-769.
