Tranexamic Acid in Postpartum Hemorrhage Management: A Multinational Systematic Review of Efficacy and Safety in Both Vaginal and Cesarean Births

Postpartum hemorrhage (PPH) is a major cause of maternal mortality worldwide, and there is an urgent need for adjuncts to uterotonic therapy. Tranexamic acid (TXA), an agent that inhibits fibrinolysis, has shown promise in surgical and trauma settings, but its role in postpartum hemorrhage prevention and treatment remains unclear. We systematically reviewed six randomized, placebo-controlled trials (total of 54934 participants) in both vaginal and cesarean delivery. Among women with postpartum hemorrhage, tranexamic acid was observed to lower the risk of bleeding-related mortality and reduce the need for additional surgical intervention. When administered prophylactically at cesarean delivery, tranexamic acid appeared to lessen intraoperative bleeding and the likelihood of severe hemorrhage or transfusion. In vaginal delivery settings, although mean blood loss was reduced, no substantial impact on the incidence of postpartum hemorrhage was noted in large-scale investigations. Overall, transfusion rates and all-cause mortality were not significantly changed. Thromboembolic events remained rare and comparable to placebo, and no maternal deaths were attributed to tranexamic acid. These findings underscore the safety and effectiveness of early administration for postpartum hemorrhage treatment. While prophylactic use at cesarean delivery confers modest reductions in severe bleeding, its role in routine prophylaxis after vaginal birth warrants further investigation. Integrating tranexamic acid into obstetric protocols may help mitigate the global burden of postpartum hemorrhage.