Tranexamic Acid for the Prevention of Blood Loss after Cesarean Delivery

Loïc Sentilhes (1) , Marie Sénat (2) , Maëla Le Lous (3) , Norbert Winer (4, 5, 6) , Patrick Rozenberg (7) , Gilles Kayem (8, 9) , Eric Verspyck (10) , Florent Fuchs (11, 12) , Elie Azria (13, 9) , Denis Gallot (14) , Diane Korb (15, 16) , Raoul Desbrière (17) , Camille Le Ray (16, 18, 9) , Céline Chauleur (19) , Fanny de Marcillac (20) , Franck Perrotin (21) , Olivier Parant (22) , Laurent Salomon (23, 16) , Emilie Gauchotte (24) , Florence Bretelle (25, 26) , Nicolas Sananès (27) , Caroline Bohec (28) , Nicolas Mottet (29) , Guillaume Legendre (30) , Vincent Letouzey (31) , Bassam Haddad (32) , Delphine Vardon (33) , Hugo Madar (1) , Aurélien Mattuizzi (1) , Valérie Daniel (30, 34) , Sophie Regueme (1) , Caroline Roussillon (1) , Antoine Benard (1) , Aurore Georget (1, 35) , Astrid Darsonval (30, 34) , Catherine Deneux-Tharaux (9)

1 CHU Bordeaux [Bordeaux]
2 Hôpital Bicêtre
3 CHU Pontchaillou [Rennes]
4 CHU Nantes - Centre hospitalier universitaire de Nantes
5 PhAN - Physiopathologie des Adaptations Nutritionnelles
6 CRNH Ouest - Centre de Recherche en Nutrition Humaine Ouest
7 Centre hospitalier intercommunal de Poissy/Saint-Germain-en-Laye - CHIPS [Poissy]
8 CHU Trousseau [APHP]
9 CRESS - U1153 - Equipe 1 : EPOPé - Épidémiologie Obstétricale, Périnatale et Pédiatrique
10 CHU Rouen
11 CHU Montpellier
12 CESP - Centre de recherche en épidémiologie et santé des populations
13 Centre hospitalier Saint-Joseph [Paris]
14 CHU Clermont-Ferrand
15 AP-HP Hôpital universitaire Robert-Debré [Paris]
16 UPCité - Université Paris Cité
17 Hôpital Saint-Joseph [Marseille]
18 Maternité Port-Royal [CHU Cochin]
19 CHU de Saint-Etienne - Centre Hospitalier Universitaire de Saint-Etienne
20 CHU Strasbourg
21 CHRU Tours - Centre Hospitalier Régional Universitaire de Tours
22 CHU Toulouse - Centre Hospitalier Universitaire de Toulouse
23 CHU Necker - Enfants Malades [AP-HP]
24 CHRU Nancy - Centre Hospitalier Régional Universitaire de Nancy
25 APHM - Assistance Publique - Hôpitaux de Marseille
26 MEPHI - Microbes évolution phylogénie et infections
27 UNISTRA - Université de Strasbourg
28 Centre hospitalier de Pau
29 CHRU Besançon - Centre Hospitalier Régional Universitaire de Besançon
30 CHU Angers - Centre Hospitalier Universitaire d'Angers
31 CHU Nîmes - Centre Hospitalier Universitaire de Nîmes
32 CHIC - Centre Hospitalier Intercommunal de Créteil
33 CHU Caen
34 CHRU Brest - Centre Hospitalier Régional Universitaire de Brest
35 BPH - Bordeaux population health

Background Prophylactic administration of tranexamic acid has been associated with reduced postpartum blood loss after cesarean delivery in several small trials, but evidence of its benefit in this clinical context remains inconclusive. Methods In a multicenter, double-blind, randomized, controlled trial, we assigned women undergoing cesarean delivery before or during labor at 34 or more gestational weeks to receive an intravenously administered prophylactic uterotonic agent and either tranexamic acid (1 g) or placebo. The primary outcome was postpartum hemorrhage, defined as a calculated estimated blood loss greater than 1000 ml or receipt of a red-cell transfusion within 2 days after delivery. Secondary outcomes included gravimetrically estimated blood loss, provider-assessed clinically significant postpartum hemorrhage, use of additional uterotonic agents, and postpartum blood transfusion. Results Of the 4551 women who underwent randomization, 4431 underwent cesarean delivery, 4153 (93.7%) of whom had primary outcome data available. The primary outcome occurred in 556 of 2086 women (26.7%) in the tranexamic acid group and in 653 of 2067 (31.6%) in the placebo group (adjusted risk ratio, 0.84; 95% confidence interval [CI], 0.75 to 0.94; P=0.003). There were no significant between-group differences in mean gravimetrically estimated blood loss or in the percentage of women with provider-assessed clinically significant postpartum hemorrhage, use of additional uterotonic agents, or postpartum blood transfusion. Thromboembolic events in the 3 months after delivery occurred in 0.4% of women (8 of 2049) who received tranexamic acid and in 0.1% of women (2 of 2056) who received placebo (adjusted risk ratio, 4.01; 95% CI, 0.85 to 18.92; P=0.08). Conclusions Among women who underwent cesarean delivery and received prophylactic uterotonic agents, tranexamic acid treatment resulted in a significantly lower incidence of calculated estimated blood loss greater than 1000 ml or red-cell transfusion by day 2 than placebo, but it did not result in a lower incidence of hemorrhage-related secondary clinical outcomes. (Funded by the French Ministry of Health; TRAAP2 ClinicalTrials.gov number, NCT03431805.) Blood-Loss Prevention after Cesarean Delivery In this trial involving women undergoing cesarean delivery (all of whom received prophylactic uterotonic medication), tranexamic acid treatment resulted in a significantly lower incidence of estimated blood loss greater than 1000 ml or red-cell transfusion by day 2 than placebo, but it did not reduce the risk of hemorrhage-related secondary clinical outcomes.

Domains: Life Sciences [q-bio]

Loïc Sentilhes, Marie Sénat, Maëla Le Lous, Norbert Winer, Patrick Rozenberg, et al.. Tranexamic Acid for the Prevention of Blood Loss after Cesarean Delivery. New England Journal of Medicine, 2021, 384 (17), pp.1623-1634. ⟨10.1056/NEJMoa2028788⟩. ⟨hal-03238593⟩