Postpartum Hemorrhage

BackgroundTranexamic acid is a recommended treatment for women with a clinical diagnosis of postpartum haemorrhage, but whether it can prevent bleeding is unclear. We conducted a systematic review and individual patient data (IPD) meta-analysis of randomised controlled trials to assess the effects of tranexamic acid in women giving birth.MethodsIn this systematic review and IPD meta-analysis, we searched the WHO International Clinical Trials Registry Platform from database inception to Aug 4, 2024 for randomised trials that assessed the effects of tranexamic acid in women giving birth. Trials were eligible if they were prospectively registered, placebo-controlled, included more than 500 women, and had a low risk of bias for random sequence generation and allocation concealment. IPD were requested from the trial investigators. The primary outcomes were the numbers of women with life-threatening bleeding and thromboembolic events. We used a one-stage model to analyse the data and explored whether the effect of tranexamic acid varied by the underlying risk of life-threatening bleeding, type of birth, presence of moderate or severe anaemia, or timing of administration (before or after a diagnosis of postpartum haemorrhage). This study is registered with PROSPERO, CRD42022345775.FindingsWe analysed data on 54 404 women from five trials. We obtained IPD for 43 409 women from four trials and aggregate data on 10 995 women from one trial. All trials had a low risk of bias. Life-threatening bleeding occurred in 178 (0·65%) of 27 300 women in the tranexamic acid group versus 230 (0·85%) of 27 093 women in the placebo group (pooled odds ratio [OR] 0·77 [95% CI 0·63-0·93]; p=0·008). There was no evidence that the effect of tranexamic acid varied by the underlying risk of life-threatening bleeding, type of birth, presence of moderate or severe anaemia or timing of administration. No significant difference was identified between tranexamic acid and placebo groups with regard to thromboembolic events: 50 (0·2%) of 26 571 women in the tranexamic acid group had fatal or non-fatal thromboembolic events versus 52 (0·2%) of 26 373 women in the placebo group (pooled OR 0·96 [0·65-1·41]; p=0·82) with no significant heterogeneity identified in the subgroup analyses.InterpretationTranexamic acid reduces the risk of life-threatening postpartum bleeding. We found no evidence that tranexamic acid increases the risk of thrombosis. Although we do not recommend the use of tranexamic acid in all women giving birth, consideration should be given to its use before a diagnosis of postpartum haemorrhage in women at high risk of death.FundingThe Bill & Melinda Gates Foundation.

Anemia affects 32 million pregnant women globally, contributing annually to more than 115 000 maternal deaths and 591 000 perinatal deaths worldwide. Low- and middle-income countries (LMICs) bear the highest burden of anemia in pregnancy, with nearly 50% of affected pregnant women. It is now 2025, which is WHO's target year for a 50% reduction in maternal anemia, and the global prevalence of anemia in pregnancy remains more than twice the target of 15%. This calls for a renewed global focus on optimal approaches for reducing the burden and complications of anemia in pregnancy. In this FIGO Childbirth and Postpartum Hemorrhage (PPH) Committee paper, current best evidence on anemia in pregnancy has been reviewed and synthesized, to make recommendations on screening, diagnosis, prevention, and treatment of anemia in pregnancy. We recommend that all pregnant women should be screened for anemia in pregnancy at booking and again at 28 weeks of pregnancy, with a full blood count (FBC), or packed cell volume/hemoglobin concentration in settings where FBC is not available. A hemoglobin concentration cutoff of less than 11 g/dL in all trimesters of pregnancy and during the postpartum period, as well as in all settings and populations, is recommended for the diagnosis of anemia in pregnancy. Routine iron and folic acid supplementation, either alone, or as components of multiple micronutrient supplements, is also recommended during pregnancy. We also made recommendations for malaria and anti-helminthic chemoprophylaxis, hemoglobinopathy screening, iron, folate, and multiple micronutrient supplementation, and blood transfusion in pregnant women with hemoglobinopathies. Finally, the relationship between anemia and postpartum hemorrhage is highlighted.

BackgroundIn this meta-analysis, we aimed to update the clinical evidence regarding the efficacy and safety of TXA in the prevention of PPH.MethodsA literature search of PubMed, Scopus, Web of Science, Google Scholar, and Cochrane Library from inception until December 2022 was conducted. We included randomized controlled trials (RCTs) comparing TXA with a placebo among pregnant women. All relevant outcomes, such as total blood loss, the occurrence of nausea and/or vomiting, and changes in hemoglobin, were combined as odds ratios (OR) or mean differences (MD) in the meta-analysis models using STATA 17 MP.ResultsWe included 59 RCTs (18,649 patients) in this meta-analysis. For cesarean birth, TXA was favored over the placebo in reducing total blood loss (MD= -2.11 mL, 95%CI [-3.09 to -1.14], P ConclusionsThis meta-analysis suggested that TXA administration is effective among women undergoing cesarean birth or vaginal birth in lowering total blood loss and limiting the occurrence of PPH. Further clinical trials are recommended to test its efficacy on high-risk populations.

BackgroundPostpartum hemorrhage (PPH) and Hypertensive Disorders of Pregnancy (HDP) remain leading causes of maternal death. This multi-country survey asked key informants to assess uptake of evidence-based practices; determine their country's implementation of updated WHO global guidelines; and describe the private sector's role in PPH and HDP management. To our knowledge, this is among the few multi-country assessments to examine national implementation of updated WHO recommendations for PPH and HDP alongside private-sector engagement across three major regions-sub-Saharan Africa, South and Southeast Asia, and Latin America and the Caribbean-providing a comparative view to guide advocacy and programme planning.MethodsFrom January to May 2022, 35 countries in sub-Saharan Africa, South and Southeast Asia, and Latin America and the Caribbean were invited to complete a survey (based on 2011 and 2012 surveys) on PPH and HDP management across public and private sectors on PPH and HDP management. Using purposive sampling, country-based focal persons assembled national expert teams from public and private sectors in health policy, education, procurement/distribution, logistics, and information systems to complete the survey. Teams produced consensus-based answers by reviewing nationally available data and policy documents. The Study Team developed composite scores for key quantitative indicators and thematically analyzed qualitative data.ResultsThirty-one countries completed the survey. Despite significant progress since 2012, several gaps remain. Oxytocin was reported as regularly available in public facilities by 77% of countries and in private facilities by 84% of countries. Magnesium sulfate was reported as available in public facilities by 58% of countries and in private facilities by 45% of countries. Interventions like umbilical vein injection of oxytocin for retained placenta (13% of countries) and heat-stable carbetocin for PPH prevention (45% of countries) were less integrated in national policy guidelines. Since 2011, midwifery scope of practice remained stagnant for manual removal of placenta for PPH, diagnosing severe pre-eclampsia/eclampsia, and giving the loading dose of MgSO4, but 60% of countries in 2022 reported that newer PPH treatments (such as tranexamic acid) were included. Quality assurance systems for procurement of essential drugs and data reporting into national information systems were deficient, particularly in the private sector.ConclusionsRecommendations include prioritizing integration of updated global guidelines; improving uptake through professional education, mentorship, and supervision; quality assurance; strengthening procurement and supply chains to improve access, availability, and quality of essential drugs and commodities; expanding midwives' scope of practice; and improving private sector governance to enhance reporting of important MNH indicators.