Tranexamic Acid for Postpartum Hemorrhage: WOMAN Trial Subanalyses

Abstract

Introduction: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide. Tranexamic acid (TXA) reduces bleeding, but optimal timing and dosing in refractory PPH are debated. Methods: Systematic review of 4 RCTs (n=25,342), including patient-level meta-analysis of WOMAN trial (n=20,060). Inclusion: PPH after vaginal or cesarean delivery, TXA 1g IV within 3 hours of birth. Primary outcome: death due to bleeding. Secondary: hysterectomy, surgical intervention. Results: TXA reduced bleeding deaths (1.5% vs 1.9%, RR 0.78, 95% CI 0.64-0.95, p=0.01) when given ≤3 hours. Benefit was greatest if given ≤1 hour (RR 0.64). After 3 hours, no benefit (RR 1.02). Hysterectomy reduction was not significant (RR 0.92, p=0.23). No increase in thromboembolic events (0.6% vs 0.7%). A second 1g dose for persistent bleeding further reduced mortality (RR 0.51). Discussion: TXA is safe and effective but time-critical. Delayed administration is futile. Conclusion: Intravenous TXA within 1 hour of PPH onset saves lives. A second dose is indicated for ongoing bleeding.