Childbirth is dangerous, even fatal. Every year, 14 million women develop postpartum haemorrhage (PPH), a dangerous complication of childbirth in which the mother can die of blood loss. A staggering 99% of the deaths occur in developing countries. Preventing death from PPH means managing the stage of birth between baby and placenta. The data couldn’t be clearer: treat it right and people live; mismanage it and women die. In the developing world, as in the West, using the right drug can save mothers. In this case, tranexamic acid has huge potential.
Why is there a problem?
Mortality from PPH has been declining steadily in the developed world for decades, but rates remain unacceptably high in the countries that are worst afflicted. This disparity is largely due to a higher prevalence of expectant (as opposed to active) management of the third stage of labour, due to chronic shortages of uterotonic drugs. However, many other factors contribute:
- Lack of experienced birth attendants to manage PPH effectively if it does occur
- Limited access to blood transfusion services
- Pre-existing comorbidities such as anaemia
Reducing maternal mortality in these countries is a global priority but has proved to be an elusive goal. The WOMAN Trial, published in the Lancet in April 2017, offers a glimmer of hope for women at risk of dying from PPH. It tested the effects of tranexamic acid (TXA), which belongs to a class of drug called antifibrinolytics. These medicines prevent breakdown of blood clots, preserving the body’s natural mechanism for stopping excessive bleeding. TXA was discovered in 1962, features on the WHO’s List of Essential Medicines and is available in a cheap generic form.
How does tranexamic acid save lives?
The CRASH-2 Trial was the first to demonstrate the benefits of tranexamic acid, proving that it reduces death in adult trauma patients with severe bleeding. The WOMAN Trial investigators built on these findings and studied the effects of TXA in 20,021 women with PPH. The women received either a single dose of TXA or an identical placebo, given by injection. They found that deaths from PPH were reduced by 19% in the group who received TXA, with no adverse effects. The reduction was even greater (31%) if the TXA was given within 3 hours of the onset of bleeding. The drug worked.
This large, well-conducted trial demonstrates that TXA has the potential to transform outcomes in PPH. Strengths include its large size, its multi-site design (incorporating 21 hospitals in countries all over the world) and its use of a low-cost readily available drug. However, one of the key barriers to implementation is the fact that the TXA was given intravenously – many facilities do not have the capacity to offer this, so future research must focus on alternative routes. Nevertheless, the WOMAN trial remains an exciting development and is cause for optimism in the ongoing challenge of reducing PPH-related maternal mortality.
Sources and Further Reading
- Postpartum haemorrhage: http://emedicine.medscape.com/article/275038-overview
- Active vs. expectant management of the third stage: https://www.ncbi.nlm.nih.gov/pubmed/20614458
- Tranexamic acid: https://www.evidence.nhs.uk/formulary/bnf/current/2-cardiovascular-system/211-antifibrinolytic-drugs-and-haemostatics/tranexamic-acid
- The CRASH-2 Trial: https://www.ncbi.nlm.nih.gov/pubmed/20554319
- The WOMAN Trial: https://www.ncbi.nlm.nih.gov/labs/articles/28456509/
- WHO Model List of Essential Medicines: http://www.who.int/medicines/publications/essentialmedicines/en/
- Image (UN Photo/Hien Macline): http://www.unmultimedia.org/s/photo/detail/509/0509486.html
At Trusted Medicine we are improving Public Health through education. We love what we do, but we need your help. Please share our work, help us reach more people.
Any opinions above are the author’s alone and may not represent those of his/her affiliations. Any comment is based on the best available evidence at the time of writing. All data is based on externally validated studies unless expressed otherwise. Novel data is representative of the sample surveyed. An online recommendation is no substitute for seeing your own doctor and should not be taken as medical advice. Article proofed and edited for publication by Dr. BM Janaway.