Postpartum Hemorrhage
Conditions
Keywords
Hemorrhage, Tranexamic acid (TXA), Estimated Blood Loss (EBL)
Brief summary
Hemorrhage remains the leading cause of maternal death worldwide. Tranexamic acid has been shown to reduce rates of hemorrhage when given prophylactically prior to cesarean delivery. It has also been shown to be an effective treatment in response to hemorrhage after a vaginal delivery. The aim of this study is to assess the impact of TXA on hemorrhage rates when given prophylactically prior to all deliveries.
Detailed description
Hemorrhage remains the leading cause of maternal mortality worldwide. In a 2014 systematic analysis of the causes of maternal death, the World Health Organization (WHO) noted that even in the face of interventions developed to actively manage the third stage of labor, 27.1% of maternal deaths were directly attributable to excessive blood loss. Risk factors for postpartum hemorrhage (PPH) have been identified, but the majority of cases occur in low risk women. As such, the routine use of oxytocin in the third stage of labor is recommended in all women and has been well documented to reduce the risk of excessive blood loss. Uterotonics such as methylergonovine, 15-methyl PGF2α and misoprostol have shown to be particularly useful adjuncts as decreased uterine tone is the most common etiology of blood loss. More recently, tranexamic acid (TXA) has been shown to be efficacious in the prevention of postpartum hemorrhage in certain cohorts. Tranexamic acid exerts its effect through the binding of plasmin and subsequent inhibition of fibrin degradation. It is regarded as pregnancy category B by the Food and Drug Administration (FDA).
Interventions
DRUGTranexamic Acid 1000 mg/10ml normal saline infusion
Infusion of Tranexamic Acid (Cyklokapron) to all consented women with the delivery of the anterior shoulder of the infant
Sponsors
United States Naval Medical Center, San Diego
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
PREVENTION
Masking
NONE
Intervention model description
Prospective Cohort
Eligibility
Sex/Gender
FEMALE
Age
18 Years to 54 Years
Healthy volunteers
Yes
Inclusion criteria
* Pregnant female presenting to Navy Medical Center San Diego for delivery * Able to speak and understand English * Planning to deliver at NMCSD
Exclusion criteria
* Age less than 18 years * Unable to speak or understand English * Not planning to deliver at NMCSD * Planned cesarean hysterectomy * Current anticoagulant use * Current subarachnoid hemorrhage * Any active/current intravascular clotting (i.e. venous thromboembolic events) * Patients with a hypersensitivity to TXA or any of the ingredients * Personal history of venous or arterial thrombotic events * Conditions that predispose patients to thromboembolic events (e.g. thrombophilias, autoimmune diseases such as lupus, active cancer, congestive heart failure, family history of thrombosis in a first degree relative at age \< 30 years) due to increased risk of thrombosis * Patients taking factor IX complex concentrates or anti-inhibitor coagulant concentrates (e.g. FEIBA NF) * Eclampsia or seizure disorder because the use of tranexamic acid has been associated with postoperative seizures * Patients with a baseline creatinine 1.2 or higher, history of renal insufficiency, or renal disease because of the risk of toxicity in patients with preexisting disease * Patients with frank hematuria because ureteral obstruction due to clot formation has been reported in patients with upper urinary tract bleeding who were treated with tranexamic acid * Patients with active or history of retinal diseases as cases of central retinal artery and central retinal vein obstruction have been reported in patients treated with intravenous tranexamic acid * Patients with acquired defective color vision
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Incidence of postpartum hemorrhage | Up to six weeks from date of delivery | Postpartum hemorrhage |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Percent decrease in hematocrit | 6 hours after hemorrhage event and as clinically indicated up to six weeks from date of delivery | Hematocrit percentage |
| Number of units of packed red blood cells transfused | Up to six weeks from date of delivery | Number of units of packed red blood cells transfused |
| Number of units of platelets transfused | Up to six weeks from date of delivery | Number of units of platelets transfused |
| Number of units of fresh frozen plasma transfused | Up to six weeks from date of delivery | Number of units of fresh frozen plasma transfused |
| Number of units of cryoprecipitate transfused | Up to six weeks from date of delivery | Number of units of cryoprecipitate transfused |
| Amount of methylergonovine administered | Up to six weeks from date of delivery | Amount of methylergonovine administered |
| Amount of 15-methyl prostaglandin F2(PGF2) administered | Up to six weeks from date of delivery | Amount of 15-methyl prostaglandin F2(PGF2) administered |
| Amount of misoprostol administered | Up to six weeks from date of delivery | Amount of misoprostol administered |
| Amount of oxytocin administered | Up to six weeks from date of delivery | Amount of oxytocin administered |
| Exploratory laparotomy following vaginal delivery due to hemorrhage | Up to six weeks from date of delivery | Exploratory laparotomy, no hysterectomy |
| Exploratory laparotomy following cesarean delivery due to hemorrhage | Up to six weeks from date of delivery | Exploratory laparotomy, no hysterectomy |
| Hysterectomy | Up to six weeks from date of delivery | Number of hysterectomies performed as a result of postpartum hemorrhage |
| Intensive Care Unit (ICU) admission | Up to six weeks from date of delivery | Number of subjects admitted to Intensive Care Unit diagnosed with postpartum hemorrhage |
| Maternal thromboembolic events | up to six weeks from date of delivery | Incidence of maternal thromboembolic events |
| Postpartum blood loss | Up to six weeks from date of delivery | Estimated blood loss (EBL) |
| Diagnosis of anemia in the neonate | Up to six weeks from date of delivery | Neonatal outcome anemia |
| Diagnosis of disseminated intravascular coagulation (DIC) in the neonate | Up to six weeks from date of delivery | Neonatal outcome DIC |
| Diagnosis of neonatal sepsis | Up to six weeks from date of delivery | Neonatal outcome sepsis |
| Diagnosis of hypoxic-ischemic encephalopathy (HIE) in the neonate | Up to six weeks from date of delivery | Neonatal outcome HIE |
| Diagnosis of a seizure disorder in the neonate | Up to six weeks from date of delivery | Neonatal outcome seizure disorder |
| Diagnosis of arrhythmia in the neonate | Up to six weeks from date of delivery | Neonatal outcome arrhythmia |
| Diagnosis of heart failure in the neonate | Up to six weeks from date of delivery | Neonatal outcome heart failure |
| Diagnosis of renal failure in the neonate | Up to six weeks from date of delivery | Neonatal outcome renal failure |
| Diagnosis of hepatic failure in the neonate | Up to six weeks from date of delivery | Neonatal outcome hepatic failure |
| Diagnosis of thromboembolic events in the neonate | Up to six weeks from date of delivery | Neonatal outcome thromboembolic event |
| Maternal mortality | Up to six weeks from date of delivery | Incidence of maternal mortality |
| Additional tranexamic acid administered | Up to six weeks from date of delivery | Additional tranexamic acid administered |
| Rate of Bakri/balloon tamponade use | Up to six weeks from date of delivery | Bakri/balloon tamponade use |
| Diagnosis of intraventricular hemorrhage in the neonate | Up to six weeks from date of delivery | Neonatal outcome intraventricular hemorrhage |
Countries
United States
Outcome results
None listed