Abstract
Background: Intravenous tranexamic acid (TXA) within 3 hours of birth significantly reduces death due to bleeding in women with postpartum haemorrhage (PPH). Most PPH deaths occur in the first hours after giving birth and treatment delay decreases survival. One barrier to rapid TXA treatment is the need for intravenous injection. Intramuscular injection and oral solution of TXA would be easier and faster to administer and would require less training. However, the pharmacokinetics (PK), pharmacodynamics and safety of TXA administered by different routes in pregnant women have not been established. The main aim of this study is to ascertain whether IM and oral solution of TXA will be absorbed at levels sufficient to inhibit fibrinolysis in pregnant women. Methods: WOMAN-PharmacoTXA is a prospective, randomised, open label trial to be conducted in Zambia and Pakistan. Adult women undergoing caesarean section with at least one risk factor for PPH will be included. Women will be randomised to receive one of the following about 1 hour prior to caesarean section: 1-gram TXA IV, 1-gram TXA IM, 4-grams TXA oral solution or no TXA. Randomisation will continue until 120 participants with at least six post randomisation PK samples are included. TXA concentration in maternal blood samples will be measured at baseline and at different time points during 24 hours after receipt of intervention. Blood TXA concentration will be measured from the umbilical cord and neonate. The primary endpoint is maternal blood TXA concentrations over time. Secondary outcomes include umbilical cord and neonate TXA concentration D-dimer concentration, blood loss and clinical diagnosis of PPH, injection site reactions and maternal and neonate adverse events. Discussion: The WOMAN-PharmacoTXA trial will provide important data on pharmacokinetics, pharmacodynamics and safety of TXA after IV, intramuscular and oral administration in women giving birth by caesarean section. Trial registration: ClincalTrials.gov, NCT04274335 (18/02/2020).
Highlights
Intravenous tranexamic acid (TXA) within 3 hours of birth significantly reduces death due to bleeding in women with postpartum haemorrhage (PPH)
The combined evidence from 40,138 patients recruited in the WOMAN and CRASH-2 trials indicates that TXA significantly increases survival from bleeding, the effect increases to 70% when the treatment is immediate after injury/childbirth (OR=1·72, 95% Confidence Interval (CI) 1·42–2·10; p
Ethics approval and consent to participate The protocol was approved by the London School of Hygiene and Tropical Medicine’s Ethics Committee, University of Zambia Biomedical Research Ethics Committee (UNZABREC, Ref: 933–2020), Zambia Medicines Regulatory Authority (ZAMRA, Reference: DMS/7/9/22/CT/102), Zambia National Health Research Authority (NHREB), National Bioethics Committee Pakistan (NBC, Ref:4-87/NBC-532/20/409), the Drug Regulatory Authority of Pakistan [DRAP, Reference: F
Summary
Intravenous tranexamic acid (TXA) within 3 hours of birth significantly reduces death due to bleeding in women with postpartum haemorrhage (PPH). The pharmacokinetics (PK), pharmacodynamics and safety of TXA administered by different routes in pregnant women have not been established. Women will be randomised to receive one of the following about 1 hour prior to caesarean section: 1-gram TXA IV, 1gram TXA IM, 4-grams TXA oral solution or no TXA. Most PPH deaths occur in low- and middle-income countries (LMICs)[2,3,4,5] Of those who survive, many suffer severe morbidity and need major interventions to control bleeding, including exploratory laparotomy, brace sutures and hysterectomy. There has been little research into different routes of administration and the pharmacokinetic (PK) properties of TXA in pregnant women have not yet been established. If absorption was rapid in pregnant women, this would strongly suggest the IM and oral routes as potential alternatives to IV use
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