Miracle drug to reduce maternal deaths
Tranexamic acid (TXA) is a game-changer drug in the treatment of post-partum haemorrhage (PPH), the main cause of death in women immediately after giving birth.
Unsurprisingly, 99 % of these deaths occur in under-developed countries like Nepal because many patients cannot afford treatment. The good news is that TXA is inexpensive, and is widely available in South Asia.
Most doctors, especially those who work in emergency room settings, have certainly heard about this drug and probably use it often. The drug’s scope is clearly not limited to PPH: it is very often used in trauma victims to stem bleeding.
However, many doctors, including those in obstetrics and gynecology, may not know why exactly this well-known and often-used drug has recently shot to prominence in the treatment of PPH.
It all had to do with the WOMAN study. In order to avoid unnecessary bias regarding drug recommendations, Western medicine is generally based on randomised, double-blind, placebo-controlled trials called RCT (randomised controlled trials).
These rigorous methods are applied so that the final results will have as little to do with chance as possible. (In fact this year’s Nobel Prize in economy went to a couple, Banerjee and Duflo,who used the RCT method to arrive at their conclusions on alleviating global poverty.)
For the TXA study, the investigators recruited women aged 16 years and older with a clinical diagnosis of post-partum hemorrhage after vaginal birth or caesarian section from 193 hospitals in 21 countries, including BPKIHS and Birat Hospital in Dharan and Nepal Medical College in Kathmandu.
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Between March, 2010 and April 2016, 20,060 women were randomly assigned by the international panel of study investigators to receive either 1 gram of intravenous TXA or a matching placebo (a look-alike sugar pill) in addition to the usual care that included other drugs.
The results were ground-breaking. When given within three hours after the onset of PPH, one in three maternal deaths were prevented with TXA. The study was published in the medical journal Lancet in May 2017. The World Health Organization (WHO) took note.
In fact the WHO had already recommended the use of TXA in PPH back in 2012, but the recommendation at that time was to use TXA almost as a last resort after the uterotonics failed to control the bleeding. Uterotonics are drugs like oxytocin and prostaglandins that are commonly used to contract the uterus to stop haemorrhage. TXA does not work by tightening the uterus but by inhibiting the breakdown of blood clots (fibrin and fibrinogen), a completely different mechanism of action.
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In 2017, based on the WOMAN trial (the World Maternal Antifibrionlytic acronym is in keeping with TXA’s mechanism of action), the WHO put out new recommendations prioritising the use of TXA in the treatment of PPH: to use it as soon as possible with the uterotonics and not to wait and watch.
This updated recommendation may not be known to many health care professionals on the frontline of post-partum haemmorhage treatment in Nepal. The use of TXA for a patient with PPH will only succeed if there is the political will to push it. Otherwise this tremendous advancement in medical care will be relegated to the dustbin.
Fortunately, the Nepal government may soon be endorsing new guidelines for the prompt use of TXA, especially in remote health facilities, to further reduce Nepal’s maternal mortality rate.
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The prompt use of TXA can also decrease the financially- devastating helicopter rescues that poor Nepali families in far-away districts have to resort to to save the lives of relatives suffering from PPH. Most cannot afford to hire helicopters and bleed to death.
In most cases, TXA has to be given intravenously, and since many Nepali births (and deaths) take place at home, this approach may not be feasible. Who is going to put in the intravenous line even if the drug is available and cheap?
Amazingly, the tablet form of the drug is already easily available in Nepal, but more research is needed to find out if giving the drug orally will achieve the same result. If TXA tablets stop post-birth bleeding as injections do, that would be very welcome news for Nepali mothers-to-be.
Buddha Basnyat, MD, is a physician at the Patan Academy of Health Sciences and writes on health issues for Nepali Times.