Tranexamic acid in postpartum hemorrhage: clinical evidence and its use in prophylaxis and treatment

Abstract

Introduction: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide. In this context, tranexamic acid (TXA), an antifibrinolytic agent, has been studied as an effective strategy for the prevention and management of PPH. The impact of PPH is significant, especially in low- and middle-income countries, where limited access to emergency obstetric care contributes to increased maternal morbidity and mortality. Therefore, investigating accessible and easily administered therapies, such as TXA, is essential for improving clinical protocols and enabling favorable maternal outcomes. Objective: To evaluate the efficacy of TXA in the prophylaxis and treatment of PPH. Methods: This is an integrative literature review conducted in March 2025, with searches in the PubMed and WHO ICTRP databases. In the PubMed database, the search strategy used the descriptors ("Tranexamic Acid"[Mesh] OR "Tranexamic Acid/therapeutic use"[MAJR] OR "TXA"[tiab]) AND ("Postpartum Hemorrhage"[Mesh] OR "Postpartum Hemorrhage/drug therapy"[MAJR] OR "Obstetric Hemorrhage"[tiab]). Randomized clinical trials published in English between 2020 and 2025 were included. In the WHO ICTRP, a search was conducted with the descriptor "tranexamic acid," using the "With results only" filter, yielding 77 articles (28 from PubMed and 49 from WHO ICTRP). After screening by title and abstract, and full-text reading, 7 clinical trials were included. Additionally, one study was manually added due to its exceptional historical relevance, totaling 8 articles for analysis. Variables were collected using a previously validated form. Results: Based on this data, prophylaxis studies consistently demonstrated that TXA, administered before cesarean incision or after vaginal delivery, significantly reduced blood loss and/or the incidence of PPH. However, the impact on reducing the need for blood transfusion was not uniformly significant in these prophylactic studies, with no statistical difference reported. Regarding the treatment of established PPH, a large-scale clinical trial showed a significant reduction in mortality from bleeding when TXA was administered early (ideally within the first three hours), but it did not find a significant reduction in the hysterectomy rate. In contrast, a later study focusing on women with PPH and pre-existing moderate to severe anemia found no benefit of TXA in reducing the progression to severe PPH or in bleeding-related mortality in this specific subpopulation. None of the eight studies analyzed reported a significant increase in thromboembolic events associated with TXA use, and there was no evidence of an increase in puerperal infections. Conclusion: This review indicates that TXA selectively improves maternal prognosis. In prophylaxis, it consistently reduces blood loss, although its impact on reducing transfusions is less clear. In the treatment of established PPH, the medication may decrease mortality from bleeding, but this benefit was not confirmed in anemic women, and the effects on transfusions or surgical interventions were inconsistent. The validation of these approaches through future studies is crucial for the development of safer and more effective clinical guidelines.