Evidence for/Against Administration of Antifibrinolytic Agents During an Obstetrical Hemorrhage

Abstract

Antifibrinolytics are lysine analogs that inhibit fibrinolysis by binding to plasminogen and preventing it from binding to a fibrin clot where it can be activated to plasmin. These drugs also bind directly to plasmin and displace it from the fibrin clot. Epsilon aminocaproic acid (amicar) and tranexamic acid (TXA) are FDA approved for the treatment of hemophilia patients for short-term use to reduce or prevent hemorrhage, and to reduce the need for replacement therapy, during and following tooth extraction. They are also approved for the treatment of cyclic heavy menstrual bleeding. This class of drug has been increasingly used to decrease blood loss associated with cardiopulmonary bypass surgery, trauma, hip, knee and spinal surgeries, and to treat thrombocytopenic patients with alloimmune refractoriness and bleeding. Several small-scale studies have shown promise in reducing obstetric hemorrhage. Recently a large randomized controlled trial showed that TXA reduces death due to bleeding from post-partum hemorrhage (PPH) with minimal adverse effects, especially if administered within 3 h of delivery. A second prospective randomized controlled trial to determine if TXA reduces the incidence of PPH is in process.