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Tranexamic Acid for use in Post Partum Haemorrhage (619)

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Intravenous Tranexamic Acid – Guidance for use in post partum haemorrhage

  • Tranexamic acid exerts an anti-fibrinolytic effect through the inhibition of plasmin. It can be used to prevent bleeding or treat bleeding associated with excessive fibrinolysis.
  • The WOMAN trial defined “clinically diagnosed post-partum haemorrhage” as clinically estimated blood loss of more than 500 ml after a vaginal birth or 1000 ml after caesarean section, or any blood loss sufficient to compromise haemodynamic stability.
  • The initial dose of TXA should be administered within 3 hours of birth, at a fixed dose of 1g (100mg/ml) intravenously at 1ml per minute (i.e. administered over 10–20 minutes). NB - infusion rate of more than 1ml/minute can cause hypotension.
  • 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
  • The use of TXA should be avoided in women with a clear contraindication to anti-fibrinolytic therapy
  • 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.

Administration

  • 1 g in 10 mls (100 mg/mL) of TXA given intravenously at an approximate rate of 1 ml 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 HELLP syndrome.
  • Upper urinary tract bleeding - may cause ureteral 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.
  • Severe pre-eclampsia / eclampsia (increased risk of seizures at high doses – risk versus benefit assessment required).
  • Concomitant administration of TXA with particular 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

Side effects

  • Hypersensitivity reactions including anaphylaxis
  • Malaise and hypotension, with or without loss of consciousness, may be seen after rapid IV injection
  • Diarrhoea
  • Nausea and vomiting
  • Dermatitis
  • 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 postoperative seizures was the same as that in untreated patients.

Breast feeding

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

Editorial Information

Last reviewed: 29/11/2022

Next review date: 28/02/2024

Author(s): Rachel Kearns.

Version: 2

Approved By: Obstetrics Clinical Governance Group

Document Id: 619