Efficacy and safety of tranexamic acid versus placebo for preventing postpartum hemorrhage after cesarean section: systematic review and meta-analysis

Abstract

Introduction. Postpartum hemorrhage is one of the leading causes of maternal morbidity and mortality worldwide. Tranexamic acid has been used as prophylaxis for postoperative blood loss. Objective. Evaluate the efficacy and safety of tranexamic acid in the prevention of postpartum hemorrhage in cesarean sections, compared to placebo. Methodology. A systematic review with meta-analysis was performed. The search was conducted in PubMed, Scopus, Web of Science, and EMBASE. The
primary outcomes were the incidence of postpartum hemorrhage, total blood loss at the end of the study, and two hours postpartum. The risk of bias was assessed using RoB 2.0 and the GRADE methodology for certainty of evidence. Meta-analyses were performed using a random-effects model and the inverse variance method. Subgroup, sensitivity, and meta-regression analyses were performed. Results. Twenty-three randomized clinical trials were included. Tranexamic acid significantly reduced total blood loss at the end of the study (SMD = -0.97; 95 % CI: -1.64 to -0.30) and two hours postpartum (SMD = -1.19; 95 % CI: -1.62 to -0.76), with consistent results in the sensitivity analysis (I2 = 0 %), especially if administered 10 to 20 minutes before the incision (MD = -170.10; 95 % CI: -229.28 to -110.93) and a reduction in the risk of postpartum hemorrhage (RR 0.84; 95 % CI: 0.76 to 0.93). Conclusion. The intervention reduced blood loss in cesarean sections when blood loss quantification and drug administration are performed in a standardized and consistent manner; it may decrease the need for blood transfusions and the use of additional uterotonics, without replacing active management of the third stage of labor. Protocol registration number. CRD42025648583.