European Journal of Cardiovascular Medicine

Postpartum hemorrhage (PPH) is a leading cause of maternal mortality and morbidity worldwide impacting millions of women every year and it accounts for 20% of all maternal deaths reported globally¹. In India, postpartum hemorrhage (PPH) occurs in approximately 2% to 4% of vaginal births and around 6% of cesarean deliveries². It is a major contributor to maternal deaths accounting for about 19.9% of maternal mortality cases in the country^3. Uterine atony is responsible for roughly 75% to 90% of all PPH incidents.³

Antifibrinolytics like tranexamic acid (TXA) diminishes the dissolution of haemostatic fibrin by plasmin ⁴Tranexamic acid (TXA) is a synthetic derivative of amino acid lysine. It competitively inhibits the activation of plasminogen to plasmin, thereby blocking the proteolytic activity of plasmin on fibrin threads thus preserving and stabilizing fibrin’s matrix structure^5. TXA’s mechanism of action involves the reversible blockage of lysine binding sites on plasminogen molecules. It has been previously used to reduce bleeding in a variety of situations, including traumatic injuries such as head trauma, perioperative and postoperative surgical bleeding⁶.

  Given the rising rates of cesarean deliveries, TXA has proven cost-effective in reducing intraoperative and postoperative bleeding and preventing postpartum hemorrhage, though evidence regarding its efficacy remains inconsistent. Therefore, the current study aims to evaluate the effectiveness of administering tranexamic acid prophylactically in reducing the blood loss during cesarean delivery.

A retrospective study was carried out by reviewing the medical records of patients who underwent caesarean sections at the Department of Obstetrics and Gynecology, Central Referral Hospital, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, between January 1 and December 31, 2023. The following inclusion and exclusion criteria were applied for selecting participants in the study:

Inclusion Criteria:

Gestation of 37 weeks or more (term pregnancy)

Primiparous or multiparous women (with a parity of two or fewer)

Singleton pregnancy

Delivered via lower segment caesarean section (LSCS)

Exclusion Criteria:

Pregnant women with hypertension or renal disorders

Those with coagulation abnormalities or a history of thromboembolic events

Multiple pregnancies

Women who had previously undergone two or more cesarean deliveries

Individuals with known allergies to tranexamic acid

A total of 120 patients were included in the study, divided into two groups: a control group consisting of 60 patients who did not receive tranexamic acid (TXA) and a study group of 60 patients who were administered 1 gram of TXA, diluted in 100 ml of saline. In the study group, TXA was administered intravenously over a 15-minute period, immediately following cord clamping, while the control group did not receive any TXA treatment. After delivery of neonate 10 units of oxytocin intravenously was administered intraoperatively to both the study and the control groups.

Preoperative hemoglobin levels were recorded for all participants to assess baseline values. Intraoperative blood loss was carefully documented following placental delivery to the end of surgery in the operating room , along with any notable postoperative bleeding. Additional data collected for analysis included the total duration of the surgery, any intraoperative complications, and hemoglobin levels measured 24 hours after surgery, which were then compared to preoperative values to evaluate the effect of TXA on blood loss and recovery. Any side effects of tranexamic acid and maternal and neonatal manifestations were noted.All LSCS were done under spinal anesthesia. There was no significant difference in the time period required to complete the lower segment caesarian section (LSCS) in both study and control groups.

Primary outcome

• Blood loss in women receiving tranexamic acid and in women who did not receive tranexamic acid

Secondary Outcome

• Difference in HB level between the two groups after 24 hrs postoperatively
• Need for additional uterotonics
• Hospital stay

Statistical Analysis: The patient data were analyzed using SPSS version 15.0 software. Depending on the type of data, the results were expressed as either means or medians with appropriate ranges. The Chi-square test was applied for comparisons of categorical data. A p-value of less than 0.05 was considered indicative of statistical significance.

Table 1: Characteristic of study population

There was no statistically significant difference in either the mean age (p > 0.05) or the period of gestation (P > 0.05) between the two groups, indicating that both groups were similar in terms of age and gestational stage.

Table 2:  Preoperative Haemoglobin and Post operative Hb level

There was no statistically significant difference in preoperative hemoglobin levels between the two groups . However, a significant reduction in postoperative hemoglobin was observed in the control group (no TXA) compared to the group that received tranexamic acid  

Table 3 : Estimated Blood Loss

In the present study, mean blood loss in the study group was 204.00 ± 104.22 mL, compared to 465.08 ± 212.98 mL in the non-TXA group. The prophylactic use of 1gm of  tranexamic acid in the study group resulted in a reduction of 261 mL in blood loss, and this difference was found to be statistically significant p value=0.001.

Table 4 :  Need for  Additional Uterotonics

The requirement for additional uterotonics, including oxytocin, carboprost, and Methergin, was significantly lower in the study group compared to the control group (p = 0.032)

Table 5: Days of Stay

TXA group had a shorter hospital stay compared to non TXA group and the difference was statistically significant with p value- 0.006.

In the present study, we evaluated the efficacy of prophylactic administration of tranexamic acid (TXA) in reducing blood loss among women undergoing cesarean delivery.

During placental delivery , the fibrinolytic system becomes activated resulting in a quick breakdown of fibrinogen and fibrin . This process is accompanied by a rise in plasminogen activators and fibrin degradation products(FDS) . Such fibrinolytic activity can persist for 6-10 hours after childbirth, potentially leading to increased bleeding . given that tranexamic acid functions as an antifibrinolytic  agent, it was utilised in this study to help minimize blood loss following lower segment caesarean section (LSCS).The results demonstrated a significant difference in the percentage of hemoglobin reduction between the study and control groups. This aligns with findings from Movafegh et al.⁷, who reported significantly lower mean blood loss in the TXA group (10 mg/kg) during both intraoperative and postoperative period also. The mean blood loss was 204.00 ± 104.22 mL in the TXA group  and  decreased need for additional uterotonics which was consistent with the study conducted by Gungorduck et al⁸ .

The adverse effects of injection tranexamic acid were monitored and the use of tranexamic acid was not associated with any side effects or complication like thrombosis, nausea, vomiting and diarrhea.

Postpartum hemorrhage (PPH) remains a leading cause of maternal morbidity and mortality, highlighting the urgent need for effective interventions. Tranexamic acid (TXA) emerges as a promising option for reducing the risk of PPH, as it has been shown to significantly decrease the need for blood transfusions and the risk of  excessive blood loss .Furthermore, TXA’s low cost and ease of administration enhance its potential to make a positive impact on healthcare outcomes.

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