Bibliographic information
GuidelineConsolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage
Year of Publication2025
Issuing InstitutionWorld Health Organization
Recommendation
New
Early use of intravenous tranexamic acid (within 3 hours of birth) in addition to standard care is recommended for women with postpartum haemorrhage after vaginal birth or caesarean section.
Recommended
Notes and Remarks
- Based on the dosing regimen used in the WOMAN trial (58), the GDG supports the administration of TXA at a fixed dose of 1 g (100 mg/mL) intravenously at 1 mL per minute (i.e. administered over 10 minutes), with a second dose of 1 g intravenously if bleeding continues after 30 minutes or if bleeding restarts within 24 hours of completing the first dose.
- The GDG acknowledged that while the WOMAN trial used clinically diagnosed PPH based on estimated blood loss or signs of haemodynamic instability, the diagnosis of PPH should no longer rely solely on clinical estimation. Therefore, this recommendation has been aligned with the updated WHO guidance on objective blood loss assessment and diagnostic criteria for PPH, which include ≥300 mL blood loss with abnormal haemodynamic signs or ≥500 mL blood loss, whichever occurs first.
- Based on evidence from the WOMAN trial, the reference point for the start of the 3-hour window for starting TXA administration is time of birth. If time of birth is unknown, the best estimate of time of birth should be used as the reference point. Because most deaths due to PPH occur within the first 2–3 hours after birth, it is critical that TXA is given as soon as possible to achieve clinical benefits.
- Analysis of the effects of timing of administration in the WOMAN trial, as well as a meta-analysis of the individual participant data of 40 138 bleeding patients (including WOMAN trial participants), indicates that TXA administration beyond 3 hours does not confer any clinical benefit. Furthermore, the point estimates of effect of TXA use beyond 3 hours on death due to trauma or after PPH were both in the direction of harm, albeit not statistically significant for women with PPH. In view of this evidence, the GDG does not support the use of TXA more than 3 hours after birth.
- Administration of TXA should be considered as part of the first-response treatment bundle (massage, administration of oxytocin, TXA, intravenous fluids, examination of the genital tract and escalation of care, to ensure timely and coordinated care) (see Recommendation 29). Other standard care in the context of this recommendation includes non-surgical temporizing measures in the management of PPH (e.g. bimanual compression, intrauterine balloon tamponade, non-pneumatic anti-shock garment, external aortic compression) and surgical interventions (e.g. brace sutures, arterial ligation or hysterectomy) in accordance with WHO guidelines or adapted local PPH treatment protocols.
- TXA should be used in all cases of PPH, regardless of whether the bleeding is due to genital tract trauma or other causes. Therefore, administration does not require the confirmation of the source of bleeding.
- The use of TXA should be avoided in women with a clear contraindication to antifibrinolytic therapy (including TXA) (e.g. a known thromboembolic event during pregnancy).
- This recommendation applies only to intravenous use. The evaluation of benefits and potential harms of other routes of TXA administration (e.g. intramuscular regimen) is a research priority.
- Regardless of the level of health system resources, TXA should be recognized as a life-saving intervention and be made readily available for the management of PPH in settings where emergency obstetric care is provided.