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Intravenous Tranexamic Acid – guidance for use in post-partum haemorrhage (619)

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Intravenous Tranexamic Acid – Guidance for use in post partum haemorrhage

  • Tranexamic acid (TXA) exerts an anti-fibrinolytic effect through the inhibition of plasmin. It can be used to prevent bleeding or treat bleeding associated with excessive fibrinolysis.
  • TXA 1g IV (over 10 minutes) should be considered if ongoing blood loss is ≥500ml.1,2. NB - infusion rate of more than 1ml/minute can cause hypotension.3
  • Initial administration of TXA beyond 3 hours does not confer any clinical benefit.
  • 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.1,3
  • A 2024 meta-analysis of six RCTs (15,981 women) examining the use of prophylactic TXA for caesarean birth found little to no difference in estimated blood loss ≥ 1000 mL, blood transfusion, uterotonic use, or surgical interventions to control bleeding when compared to placebo with standard care or standard care alone.4   
  • There is no signal relating to an increase in thromboembolic events in women who receive TXA, but data remain insufficient to make firm conclusions.4
  • Prophylactic use of TXA in women undergoing caesarean birth is not routinely recommended but may be considered, depending on potential risks and benefits, in individual cases at high risk of PPH.4
  • The World Health Organization (WHO) issued a safety alert relating to reports of fatality following inadvertent intrathecal injection of TXA. Glass vials of TXA and Bupivacaine can be similar in appearance resulting in wrong drug errors. TXA is profoundly neurotoxic and should be stored in a separate area to Bupivacaine for intrathecal use and other local anaesthetics. In particular, TXA must NOT be stored on any trolley or area reserved for neuraxial equipment.5
  • TXA is just one part of PPH management. Surgical source control and haemostasis, early resuscitation, involvement of senior staff and management of coagulopathy remain the most important interventions.

Formulation

  • Tranexamic acid (Cyclokapron) 100mg/ml. Clear, colourless fluid for injection supplied as a glass ampoule of 1 g in 10ml.6,7

Administration

  • 1 g in 10ml (100 mg/mL) of TXA given intravenously at an approximate rate of 1ml per min (ie. over 10 minutes). This should be given within 3 hours of the start of PPH and can be repeated if bleeding continues after 30 minutes, or if bleeding restarts within 24 hours of completing the first dose.
  • TXA should not be mixed with blood for transfusion or any intravenous penicillin preparations, including co-amoxiclav.

Contraindications

  • Active intravascular clotting e.g. DIC (unless predominant activation of fibrinolytic system with severe bleeding), TTP, severe pre-eclampsia, severe HELLP syndrome.
  • Upper urinary tract bleeding - may cause ureter obstruction due to clot formation.
  • Hypersensitivity to TXA.
  • Subarachnoid haemorrhage - may cause cerebral oedema / infarction

Cautions

  • The dose of TXA should be reduced in patients with renal insufficiency because of the risk of accumulation.
  • Patients with a recent history (< 12 weeks) of arterial or venous thrombosis.
  • Concomitant administration of TXA with coagulation factor concentrates i.e.  rVIIa, FVIII inhibitor bypassing agent (FEIBA) should be avoided as the risk of thrombosis may be increased.

Renal impairment

  • The dose of TXA should be reduced in patients with renal failure due to the risk of accumulation.
  • For patients with mild to moderate renal impairment, the dosage of TXA should be reduced according to the serum creatinine level, see table below.

Serum creatinine in µmol/l

Dose IV

Administration

 

120-249

10 mg/kg

Every 12 hours

250-500

10 mg/kg

Every 24 hours

>500

5 mg/kg

Every 24 hours

Side effects

  • Hypersensitivity reactions, including anaphylaxis.
  • Malaise and hypotension, with or without loss of consciousness, may be seen after rapid IV injection.
  • Nausea and vomiting.
  • Impairment of colour vision – discontinue treatment if this occurs.
  • Seizures – cases of convulsions have been reported in association with TXA treatment. In coronary artery bypass graft (CABG) surgery, most of these cases were reported following IV injection of TXA in high doses. With the use of the recommended lower doses of TXA, the incidence of post-operative seizures was the same as that in untreated patients.

Breast feeding

Small amount present in milk. Anti-fibrinolytic effect on infants is unlikely.

Editorial Information

Last reviewed: 06/05/2025

Next review date: 31/05/2028

Author(s): Rachel Kearns, Jill Keohone.

Version: 3

Author email(s): rachel.kearns2@nhs.scot, jill.keohone2@nhs.scot.

Approved By: Maternity Clinical Governance Group

Document Id: 619