Adjunctive IV tranexamic acid versus topical tranexamic acid application of the placental bed for prevention of postpartum hemorrhage in women with placenta previa: a randomized controlled trial

Nahla W. Shady, Hany F. Sallam


Background: Placenta previa one of the famous etiology of excessive blood loss during and after cesarean section. The objective of this study was to determine the effect of prophylactic adjunctive IV versus topical tranexamic acid (TA) on calculated and measured blood loss during and after caesarean section due to placenta previa compared with standard IV oxytocin alone.

Methods: In this double-blind randomized controlled trial, 120 women were undergoing caesarean delivery for placenta previa (PP) were randomly allocated to receive 10 IU oxytocin IV after placental delivery, or receive 1 gm tranexamic acid IV just before skin incision plus 10 IU oxytocin IV after placental delivery or received 10 IU oxytocin IV after placental delivery plus 2 gm topical tranexamic acid applied on placental bed. The main outcome was to measure blood loss during and 4-hour post caesarean delivery.

Results: 120 women were enrolled (n = 40 in each group). Both groups of women received IV tranexamic acid (Group II) and topical tranexamic acid (Group III) showed great reduction in intraoperative and 4 hours post-operative blood loss compared with (Group I) which received 10 IU oxytocin only (P = 0.0001, 0.0001, 0.0001, 0.0001), so the overall estimated blood loss in group II and III showed highly reduction compared with group I (P = 0.0001, 0.0001).

Conclusions: Prophylactic adjunctive TA topical application on the placental bed or iv administration reduces blood loss during and after caesarean delivery in women with a placenta previa. novel application of topical tranexamic acid on the placental bed is effective in reduce intraoperative and postoperative bleeding in comparison with IV route with elimination of theoretical risk of thrombi embolism complication with IV rout.


Oxytocin, Placenta previa, Post-partum hemorrhage, Tranexamic acid

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Prata N, Gerdts C. Measurement of postpartum blood loss. BMJ. 2010;340:c555.

Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2:e323-e333.

Reddy UM, Abuhamad AZ, Levine D. Executive summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society of Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop. J Ultrasound Med. 2014 May;33(5):745-57.

Vergani P, Ornaghi S, Pozzi I, et al: Placenta previa: distance to internal os and mode of delivery. Am J Obstet Gynecol. 2009;201:266.

WHO. WHO recommendations for the prevention and treatment of postpartum haemorrhage. World Health Organisation, Geneva; 2012

CRASH-2 collaborators. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomized controlled trial. Lancet. 2011;377(9771):1096-101.

Simonazzi G, Bisulli M, Saccone G, Moro E, Marshall A, Berghella V. Tranexamic acid for preventing postpartum blood loss after cesarean delivery: a systematic review and meta-analysis of randomized controlled trials. Acta Obstet Gynecol Scand. 2016;95:28-37.

Ipema HJ, Tanzi MG. Use of topical tranexamic acid or aminocaproic acid to prevent bleeding after major surgical procedures. Ann Pharmacother. 2012;46:97-107

Menard MK, Main EK, Currigan SM. Executive summary of the revitalize initiative: standardizing obstetric data definitions. Obstet Gynecol. 2014;124:150-3.

Likis FE, Sathe NA, Morgans AK, Hartmann KE, Young JL, Carlson-Bremer D, et al. Management of postpartum hemorrhage. Comparative effectiveness Review No. 151. AHRQ Publication No. 15-EHC013-EF. Rockville (MD): Agency for Healthcare Research and Quality; 2015.

Westhoff G, Cotter AM, Tolosa JE. Prophylactic oxytocin for the third stage of labor to prevent postpartum hemorrhage. Cochrane Database Sys Rev. 2013;10:CD001808.

Evensen A, Anderson JM, Fontaine P. Postpartum hemorrhage: prevention and treatment. Am Fam Physician. 2017;95:442-9.

Poeran J, Rasul R, Suzuki S, Danninger T, Mazumdar M, Opperer M, et al. Tranexamic acid use and postoperative outcomes in patients undergoing total hip or knee arthroplasty in the United States: retrospective analysis of effectiveness and safety. BMJ. 2014;349:4829.

Gai MY, Wu LF, Su QF, Tatsumoto K. Clinical observation of blood loss reduced by tranexamic acid during and after caesarian section: a multi-center, randomized trial. Eur J Obstet Gynecol Reprod Biol. 2004;112(2):154-7.

Gungorduk K, Yildirm G, Asicioğlu O, Gungorduk OC, Sudolmus S, Ark C. Efficacy of intravenous tranexamic acid in reducing blood loss after elective cesarean section: a prospective, randomized, double-blind, placebo-controlled study. Am J Perinatol. 2011;28(3):233-40

Abdel-Aleem H, Alhusaini TK, Abdel-Aleem MA, Menoufy M, Gulmezoglu AM. Effectiveness of tranexamic acid on blood loss in patients undergoing elective cesarean section: randomized clinical trial. J Matern Fetal Neonatal Med. 2013;26:1705-9

Sarris I, Arafa A, Konaris L, Kadir RA. Topical use of tranexamic acid to control perioperative local bleeding in gynecology patients with clotting disorders: two cases. Haemophilia. 2007;13:115-6.

Perel P, Ker K, Morales Uribe CH, Roberts I. Tranexamic acid for reducing mortality in emergency and urgent surgery. Cochrane Database Syst Rev. 2013;1:CD010245.

Roberts I, Fawole B, Chaudhri R, El-Sheikh M, Akintan A, Qureshi Z, et al. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum hemorrhage (WOMAN): an international, randomized, double-blind, placebo-controlled trial. Lancet. 2017;389 (10084):2105-16.

Movafegh A, Eslamian L, Dorabadi A. Effect of intravenous tranexamic acid administration on blood loss during and after cesarean delivery. Int J Gynaecol Obstet. 2011;115:224-6.

Senturk MB, Cakmak Y, Yildiz G, Yildiz P. Tranexamic acid for cesarean section: a double blind, placebo controlled, randomized clinical trial. Arch Gynecol Obstet. 2013;287:641-5.

Ahmed MR, Sayed Ahmed WA, Madny EH, Arafa AM, Said MM. Efficacy of tranexamic acid in decreasing blood loss in elective caesarean delivery. J Matern Fetal Neonatal Med. 2015;28:1014-8.

Goswami U, Sarangi S, Gupta S, Babbar S. Comparative evaluation of two doses of tranexamic acid used prophylactically in anemic parturients for lower segment cesarean section: a double-blind randomized case control prospective trial. Saudi J Anaesth. 2013;7:427-31.