Intravenous tranexamic acid vs. sublingual misoprostol in high-risk women for postpartum haemorrhage following cesarean delivery; a randomised clinical trial

Abstract

Objective
This study compares the effectiveness of administering sublingual misoprostol combined with oxytocin to that of IV tranexamic acid combined with oxytocin to reduce intra and post-operative blood loss in high-risk women for postpartum haemorrhage (PPH) following cesarean section (CS).

Methods
About 315 high-risk pregnant women undergoing CS participated in this trial. They were randomly assigned into three groups; tranexamic group, misoprostol group, and control group, according to the medication given in the operative theatre. All patients received oxytocin intraoperatively. They were assessed regarding intraoperative blood loss, the incidence of PPH, and the reduction in haemoglobin and hematocrit values.

Results
Both tranexamic and misoprostol groups had similar results in reducing intra and post-operative blood loss. However, the reduction in haemoglobin and hematocrit were significantly lower in tranexamic and misoprostol groups compared to the control group (-0.78 ± 0.57 vs. -0.83 ± 0.52 vs. -1.32 ± 0.57 gm/dl, P < 0.001 and − 3.05 ± 1.28 vs. -3.06 ± 1.13 vs. -4.94 ± 1.82%, P < 0.001 respectively). In addition, the estimated blood loss was significantly lower in the tranexamic and misoprostol groups compared to the control group (641.6 ± 271.9 vs. 617.9 ± 207.4 vs. 1002.4 ± 340.7 ml, P < 0.001).

Conclusion
Both tranexamic acid and misoprostol are equally capable of reducing blood loss, but the results were significantly better compared to using oxytocin alone in high-risk patients.

Clinical Trial Registration
Registered at www.clinicaltrials.govon07/10/2019 with registration number NCT04117243.

Full text

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Dawoud et al. BMC Pregnancy and Childbirth (2023) 23:611
https://doi.org/10.1186/s12884-023-05935-5 BMC Pregnancy and Childbirth
*Correspondence:
Mazen Abdel-Rasheed
doctor_mazen@hotmail.com
1Obstetrics and Gynaecology Department, Faculty of Medicine, Cairo
University, Cairo, Egypt
2Reproductive Health Research Department, National Research Centre, 33
El-Buhouth St, Dokki, 12622 Cairo, Egypt
Abstract
Objective This study compares the eectiveness of administering sublingual misoprostol combined with oxytocin to
that of IV tranexamic acid combined with oxytocin to reduce intra and post-operative blood loss in high-risk women
for postpartum haemorrhage (PPH) following cesarean section (CS).
Methods About 315 high-risk pregnant women undergoing CS participated in this trial. They were randomly
assigned into three groups; tranexamic group, misoprostol group, and control group, according to the medication
given in the operative theatre. All patients received oxytocin intraoperatively. They were assessed regarding
intraoperative blood loss, the incidence of PPH, and the reduction in haemoglobin and hematocrit values.
Results Both tranexamic and misoprostol groups had similar results in reducing intra and post-operative blood
loss. However, the reduction in haemoglobin and hematocrit were signicantly lower in tranexamic and misoprostol
groups compared to the control group (-0.78 ± 0.57 vs. -0.83 ± 0.52 vs. -1.32 ± 0.57 gm/dl, P < 0.001 and − 3.05 ± 1.28 vs.
-3.06 ± 1.13 vs. -4.94 ± 1.82%, P < 0.001 respectively). In addition, the estimated blood loss was signicantly lower in the
tranexamic and misoprostol groups compared to the control group (641.6 ± 271.9 vs. 617.9 ± 207.4 vs. 1002.4 ± 340.7
ml, P < 0.001).
Conclusion Both tranexamic acid and misoprostol are equally capable of reducing blood loss, but the results were
signicantly better compared to using oxytocin alone in high-risk patients.
Clinical Trial Registration Registered at www.clinicaltrials.govon07/10/2019 with registration number
NCT04117243.
Keywords Misoprostol, Oxytocin, Postpartum haemorrhage, Tranexamic acid
Intravenous tranexamic acid vs. sublingual
misoprostol in high-risk women
for postpartum haemorrhage following
cesarean delivery; a randomised clinical trial
MariamDawoud1, MahaAl-Husseiny1, OmneyaHelal1, MoutazElsherbini1, MazenAbdel-Rasheed2* and
MonaSediek1
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Dawoud et al. BMC Pregnancy and Childbirth (2023) 23:611
Introduction
e cesarean section (CS) rate is still sharply grow-
ing, as CS is the commonest major obstetric procedure
performed worldwide [1]. Despite the advances in the
medical eld, obstetric haemorrhage remains a well-
recognised complication of childbirth in both developed
and developing countries [2, 3]. Obstetric haemorrhage is
identied as the second leading cause of maternal mor-
tality in developed countries while considered the pri-
mary cause of maternal mortality in developing countries
[4, 5].
Postpartum haemorrhage (PPH), either primary or
secondary, is considered one of the commonest types of
obstetric haemorrhage. In 2017, the American College of
Obstetrics and Gynecology updated the denition of pri-
mary PPH to be a cumulative blood loss higher than 1000
mL with clinical features of hypovolemia within 24h of
birth, regardless of the delivery route [6]. Uterine atony,
lacerations, retained tissues or blood clots and coagula-
tion factor deciencies are the most common causes of
PPH. e management strategies include uterine mas-
sage, oxytocin, methylergometrine, and circulatory sup-
port with or without blood transfusion. It has been
estimated that about 5% of cesarean delivery may experi-
ence PPH [7, 8].
Since prevention of PPH is the cornerstone of manage-
ment, the National Collaborating Centre for Women’s
and Children’s Health has recommended the administra-
tion of intravenous 5 IU of oxytocin routinely following
the cesarean delivery as a prophylactic measure against
PPH [9].
Several studies have assessed the use of other agents in
addition to oxytocin for the prophylaxis against PPH fol-
lowing CS. Misoprostol, a prostaglandin E1 analogue, has
been introduced as a uterotonic agent to prevent PPH
after CS. A Cochrane review has concluded that the com-
bination of misoprostol and oxytocin was one of the most
eective combinations in reducing blood loss compared
to oxytocin alone [10]. In addition, WHO has issued a
statement recommending the distribution of misopros-
tol among pregnant women in low-source countries to be
used after delivery to reduce blood loss [11].
Tranexamic acid is an antibrinolytic medication that
acts by blocking lysine binding sites on plasminogen mol-
ecules. Several studies have addressed its use in prevent-
ing PPH following CS and showed the eectiveness of
tranexamic acid when added to oxytocin in preventing
blood loss [12, 13]. A Cochrane review has also shown its
eectiveness when used alone in a dose of 0.5-1 gm intra-
venously in low-risk women for PPH. However, it was
concluded that further studies were required to assess its
safety prole and its use in high-risk women [14].
Our study aimed to reach the most eective protocol in
reducing intra and post-operative blood loss in high-risk
women for PPH following CS. erefore, we compared
the eectiveness of the combined use of sublingual miso-
prostol and IV oxytocin with that of the combined use
of IV tranexamic acid and oxytocin. Also, we compared
them with the eectiveness of oxytocin when given alone.
Methods
A randomised clinical trial was carried out, following the
CONSORT guidelines, in Kasr Al-Ainy Hospital (Obstet-
rics and Gynaecology Department, Faculty of Medi-
cine, Cairo University) from January 2020 to December
2020 after approval of the Medical Ethical Committee.
Informed consent was obtained from all participants
after explaining the nature of the study, expected value,
outcome, and possible adverse eects. is clinical trial
was registered at www.clinicaltrials.govon07/10/2019
with registration number NCT04117243.
e study included 345 pregnant women who were
candidates for lower segment cesarean section (LSCS)
under spinal anaesthesia. Inclusion criteria were mater-
nal age 20–40 years, term pregnancy (≥ 37 weeks),
with one or more of the high risk for PPH criteria [15].
ese criteria included: (1) maternal anaemia (haemo-
globin < 9.9g%), (2) chronic maternal medical disorders
(e.g., cardiac, renal, DM), (3) preeclampsia or gestational
hypertension, (4) macrosomia, (5) high-risk cases for
obstetric haemorrhage (e.g., peripartum haemorrhage,
accidental haemorrhage, placenta previa, previous his-
tory of uterine atony or PPH).
On the other hand, exclusion criteria were (1) intra-
uterine fetal death (IUFD), (2) fetal anomalies or growth
retardation (FGR), (3) emergency CS, (4) more than two
previous CS procedures, (5) prolonged procedure (more
than two hours from skin incision to skin closure), (6)
abnormally invasive placenta, (7) known or history of
thromboembolic events, (8) history of prostaglandin or
Tranexamic acid allergy.
All participants underwent the following steps to con-
rm their eligibility for this study: (1) full medical and
obstetric history, (2) general and obstetric examination,
(3) obstetric ultrasound, and (4) pre-operative laboratory
tests: including complete blood count (CBC), coagulation
prole, and liver and kidney function tests.
On the day of the scheduled surgery, the participants
were randomly assigned into three groups; Tranexamic
Group, Misoprostol Group, and Oxytocin-only Group
(as a control group). Randomisation was performed using
computer-generated random numbers.
In the tranexamic group, 1 gm (10 ml) of tranexamic
acid (Kapron, Amoun, Egypt) was diluted in 20 ml of
Glucose 5%, then given to the patients as an intravenous
infusion over 5min, at least 15min before skin incision.
In the misoprostol group, 400 micrograms of misopro-
stol (2 tablets - Cytotec, Pzer, G.D. Searle LLC) were
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Dawoud et al. BMC Pregnancy and Childbirth (2023) 23:611
administered sublingually by the patients immediately
before starting the skin incision.
Following the baby’s delivery, all patients in the three
groups received an intravenous bolus of 5 IU oxytocin
(Syntocinon, Novartis, Basel, Switzerland) and 20 IU oxy-
tocin in 500 mL lactated Ringer’s solution (infused at a
rate of 125 mL/h). e operative time was recorded, the
blood volume in the suction unit was observed, and the
number of operative towels was counted.
All patients were observed for primary PPH for the
rst 24h. ey were also followed regarding the occur-
rence of misoprostol-related side eects (shivering,
pyrexia > 38 C, headache, nausea, and vomiting in the
rst 6h) and the occurrence of tranexamic acid-related
side eects (thromboembolic events within one week of
delivery).
CBC was repeated 12 h after delivery, and the esti-
mated blood loss (EBL) after CS was calculated by this
formula:
EB
L=EBV
×Pre−operativehematocrit−Postoperativehematocrit
Pre−operativehematocrit,
where EBV is the estimated blood volume of the patient
in mL = weight in kg × 85 [16].
e primary outcome was to compare the estimated
blood loss (EBL) during and after cesarean delivery
among the three groups, while the secondary outcomes
were to evaluate the incidence of PPH and the possible
side eects.
Sample size calculation
e sample size was calculated with PASS 11 software
(NCSS, LLC. Kaysville, Utah, USA). e sample size of 95
for each group achieves 90% power to detect a dierence
of 100.8 between the null hypothesis and the alternative
hypothesis that their means are 499.9 and 600.7 with esti-
mated group standard deviations of 206.4 and 215.7 and
with a signicance level (alpha) of 0.05 using a two-sided
two-sample t-test [17]. e sample size was increased by
20% to be 114 for each group to allow for dropouts.
Statistical methods
Recorded data were analysed using the statistical pack-
age for the Social Sciences (SPSS) version 25. Quantita-
tive variables were summarised in the form of mean and
standard deviation, while categorical variables were sum-
marised in the form of numbers and percentages. e
numerical data were compared with a one-way analysis
of variance (ANOVA) when comparing between means
and with the Kruskall-Wallis test if the data were non-
parametric. For comparing the categorical data, a Chi-
square (x2) test was performed. P values less than 0.05
were considered statistically signicant.
Results
In this clinical trial, 345 pregnant women met the inclu-
sion criteria and assigned to three groups, as shown
in the owchart of patients in Fig.1. e demographic
and clinical characteristics of the participants are dem-
onstrated in Table 1. All groups had no signicant dif-
ference regarding maternal age, BMI, parity, indication
for CS, gestational age at delivery, pre-operative Hb and
HCT, and operative time.
e maternal outcomes are shown in Tables 2 and 3.
Both tranexamic and misoprostol groups had similar
results regarding the post-operative Hb and HCT, the
reduction in Hb and HCT values, the blood loss in the
suction apparatus and the EBL. ere were no signicant
dierences between both groups.
Unlike that, the post-operative Hb and HCT values
were signicantly higher in the tranexamic and misopro-
stol groups compared to the control group (P < 0.001).
Subsequently, the reduction in Hb and HCT values was
signicantly lower in tranexamic and misoprostol groups
compared to the control (P < 0.001). In addition, blood
loss in the suction apparatus and EBL were signicantly
lower in the tranexamic and misoprostol groups than in
the control group (P < 0.001). However, there was no sig-
nicant dierence between all groups regarding the inci-
dence of PPH in the rst 24h and the side eects.
Discussion
In this study, the combined use of sublingual misopros-
tol and IV oxytocin was equally eective as the combined
use of IV tranexamic acid and oxytocin in decreasing
blood loss in high-risk women undergoing CS. Mean-
while, compared to using oxytocin alone, both protocols
were superior in reducing the amount of blood loss.
Hemapirya L et al. (2020) reached similar results,
although they included 200 low-risk women candidates
for LSCS, who were randomised equally randomised
into two groups; the study group in which tranexamic
acid was given before skin incision at a dose of 10 ml/
kg in 100 ml saline, and a control group which was given
the standard 10 IU oxytocin intravenously following the
delivery of the baby. e study group had less blood loss
and higher post-operative haemoglobin when compared
to the control group [18].
In a meta-analysis by Simonazzi et al. (2016) that
included 2365 women from nine trials, the pre-opera-
tive use of tranexamic acid was associated with lower
blood loss, less haemoglobin drop and lower incidence
of PPH; when compared to the control who had oxyto-
cin alone [19]. Another systematic review came with
the same results regarding the eect of tranexamic
acid on decreasing peripartum blood loss. However,
only minor side eects were reported following its use,
such as shivering and nausea, with no increased risk of
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Dawoud et al. BMC Pregnancy and Childbirth (2023) 23:611
thromboembolism. Yet, the authors had safety concerns
over the use of tranexamic acid. ey explained that the
trial was of moderate quality [20].
Regarding the role of adding sublingual misoprostol to
oxytocin in preventing PPH, previous studies revealed
similar results to our ndings [21, 22]. Chaudhuri and
Majumdar (2015) studied the eect of sublingual miso-
prostol in a dose of 400 mcg versus placebo in 198
women undergoing emergency CS and at high risk for
blood loss. In their study, misoprostol was given follow-
ing delivery of the baby, unlike in our study, in which
misoprostol was given before skin incision. ey also
Table 1 Basic demographic and clinical characteristics of the participants
Tranexamic Group
(n = 115)
Misoprostol Group
(n = 115)
Control Group (n = 115) P-
val-
ue
Maternal age (years) 29.59 ± 4.15 28.70 ± 4.51 29.90 ± 5.15 0.125
BMI (kg/m2) 30.56 ± 3.60 30.54 ± 4.30 30.19 ± 3.44 0.903
Parity
- Primigravida
- Para 1
- Para 2 or more
7 (6.09%)
13 (11.30%)
95 (82.61%)
8 (6.96%)
9 (7.83%)
98 (85.22%)
7 (6.09%)
18 (15.65%)
90 (78.26%)
0.480
GA at delivery 38.46 ± 0.97 38.50 ± 0.96 38.38 ± 0.95 0.622
CS Indication
- previous CS
- CPD
- Abnormal presentation
- Placenta Previa
- ICSI
86 (74.8%)
3 (2.6%)
11 (9.6%)
12 (10.4%)
3 (2.6%)
86 (74.8%)
5 (4.3%)
9 (7.8%)
11 (9.6%)
4 (3.5%)
76 (66.1%)
8 (7.0%)
15 (10.4%)
14 (12.2%)
2 (1.7%)
0.667
Pre-operative Hb (gm/dl) 11.17 ± 0.89 11.42 ± 1.05 11.21 ± 1.11 0.146
Pre-operative HCT (%) 34.20 ± 2.64 34.94 ± 3.42 34.70 ± 3.24 0.188
Estimated blood volume (ml) 7169 ± 546 7121 ± 719 7108 ± 556 0.726
CS Duration (minutes) 73.88 ± 14.95 77.19 ± 11.12 74.24 ± 15.26 0.142
Interval from skin incision to complete fetal
and placental extraction (minutes)
15.15 ± 1.14 15.10 ± 0.89 14.95 ± 1.38 0.385
Fig. 1 Flow diagram of patients in the study
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Dawoud et al. BMC Pregnancy and Childbirth (2023) 23:611
Table 2 Maternal outcomes in Caesarean section
Tranexamic Group
(n = 115)
Misoprostol Group
(n = 115)
Control Group (n = 115) P-value
Number of soaked towels 5 (2–10) 4 (2–9) 6 (2–10) < 0.001*
Blood loss in suction apparatus (ml) 247.4 ± 115.6 248.7 ± 93.5 395.2 ± 142.2 < 0.001*
Post-operative Hb (gm/dl) 10.39 ± 0.87 10.58 ± 1.03 9.89 ± 1.07 < 0.001*
Hb dierence (gm/dl) -0.78 ± 0.57 -0.83 ± 0.52 -1.32 ± 0.57 < 0.001*
Post-operative HCT (%) 31.15 ± 2.62 31.88 ± 3.38 29.76 ± 3.07 < 0.001*
HCT dierence (%) -3.05 ± 1.28 -3.06 ± 1.13 -4.94 ± 1.82 < 0.001*
Estimated blood loss (ml) 641.6 ± 271.9 617.9 ± 207.4 1002.4 ± 340.7 < 0.001*
Incidence of postpartum haemorrhage in 1st 24h 2 (1.74%) 1 (0.87%) 3 (2.61%) 0.601
Side eects 1 (0.9%) 0 (0.0%) 0 (0.0%) 0.367
Table 3 Comparison between the three groups regarding
Groups Mean Dierence (X-Y) P-value 95% Condence
Interval
Lower Upper
Post-operative Hb (gm/dl) Control (X) Tranexamic (Y) -0.50 < 0.001* -0.808 -0.192
Misoprostol (Y) -0.70 < 0.001* -1.004 -0.388
Tranexamic (X) Control (Y) 0.50 < 0.001* 0.192 0.808
Misoprostol (Y) -0.20 0.294 -0.504 0.112
Misoprostol (X) Control (Y ) 0.70 < 0.001* 0.388 1.004
Tranexamic (Y) 0.20 0.294 -0.112 0.504
Hb dierence (gm/dl) Control (X) Tranexamic ( Y) -0.54 < 0.001* -0.708 -0.363
Misoprostol (Y) -0.49 < 0.001* -0.659 -0.314
Tranexamic (X) Control (Y) 0.54 < 0.001* 0.363 0.708
Misoprostol (Y) 0.05 0.779 -0.123 0.222
Misoprostol (X) Control (Y ) 0.49 < 0.001* 0.314 0.659
Tranexamic (Y) -0.05 0.779 -0.222 0.123
Post-operative HCT (%) Control (X) Tranexamic (Y) -1.39 0.002 -2.333 -0.446
Misoprostol (Y) -2.12 < 0.001* -3.063 -1.175
Tranexamic (X) Control (Y) 1.39 0.002 0.446 2.333
Misoprostol (Y) -0.73 0.165 -1.673 0.214
Misoprostol (X) Control (Y ) 2.12 < 0.001* 1.175 3.063
Tranexamic (Y) 0.73 0.165 -0.214 1.673
HCT dierence (%) Control (X) Tranexamic (Y) -1.89 < 0.001* -2.342 -1.446
Misoprostol (Y) -1.89 < 0.001* -2.334 -1.438
Tranexamic (X) Control (Y) 1.89 < 0.001* 1.446 2.342
Misoprostol (Y) 0.01 0.999 -0.440 0.456
Misoprostol (X) Control (Y ) 1.89 < 0.001* 1.438 2.334
Tranexamic (Y) -0.01 0.999 -0.456 0.440
Estimated blood loss (ml) Control (X) Tranexamic (Y) 360.74 < 0.001* 274.219 447.260
Misoprostol (Y) 384.43 < 0.001* 297.914 470.955
Tranexamic (X) Control (Y) -360.74 < 0.001* -447.260 -274.219
Misoprostol (Y) 23.70 0.795 -62.825 110.216
Misoprostol (X) Control (Y ) -384.43 < 0.001* -470.955 -297.914
Tranexamic (Y) -23.70 0.795 -110.216 62.825
Blood loss in suction apparatus (ml) Control (X) Tranexamic (Y) 147.83 < 0.001* 110.948 184.704
Misoprostol (Y) 146.52 < 0.001* 109.644 183.399
Tranexamic (X) Control (Y) -147.83 < 0.001* -184.704 -110.948
Misoprostol (Y) -1.30 0.996 -38.182 35.573
Misoprostol (X) Control (Y ) -146.52 < 0.001* -183.399 -109.644
Tranexamic (Y) 1.30 0.996 -35.573 38.182
a P-value is sig nicant (ANOVA test with Tukey Post Hoc tes t)
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Dawoud et al. BMC Pregnancy and Childbirth (2023) 23:611
used 20 U of oxytocin IV following delivery of the baby
in both groups, whereas we used 10 U of oxytocin. e
misoprostol group showed a signicantly lower mean
intraoperative blood loss compared to the placebo group;
however, the post-operative blood loss was slightly lower
in the misoprostol group. Side eects such as shivering
and pyrexia were reported more in the misoprostol group
[21].
In a former study, Fekih et al. (2009) compared the
role of sublingual misoprostol administration (in a dose
of 200 mcg) at cord clamping together with oxytocin at
a dose of 20 U (10 U bolus dose and 10 U infusion in 500
ml lactated Ringer), with that of giving oxytocin alone at
the same dose in 250 low-risk women undergoing elec-
tive CS. e combined misoprostol and oxytocin group
showed less blood loss and less haemoglobin drop than
the oxytocin-only group. Again, the combined misopro-
stol and oxytocin group showed more adverse eects,
such as shivering and pyrexia [22].
Although we found that pre-operative use of sublin-
gual misoprostol was equally eective as that of intrave-
nous tranexamic acid to prevent PPH in high-risk women
undergoing CS, a previous study by Tabatabaie et al.
(2021) revealed that misoprostol is more eective than
tranexamic acid in reducing the blood loss intra- and
post-operatively [23]. e possible explanation for miso-
prostol superiority is that they enrolled their study on a
non-risk population. On the contrary, Bose and Beegum
(2017) found that tranexamic acid is superior to miso-
prostol in reducing blood loss in non-risk women. How-
ever, they found tranexamic acid and misoprostol equally
eective in reducing blood loss in high-risk women,
which agrees with our results.
e strength of our study is comparing the eective-
ness and safety of sublingual misoprostol to that of IV
tranexamic acid, as well as to that of oxytocin alone in
preventing PPH IN high-risk pregnant women undergo-
ing CS. Our randomised study had a large sample size,
and we used dierent methods to evaluate the eective-
ness of each management protocol. However, the main
limitation is that our study was open-label, and our pop-
ulation had various risk factors. Also, we did not study
the eect of dierent doses of misoprostol.
Conclusion
In clinical practice, both IV tranexamic acid and sub-
lingual misoprostol, when used along with oxytocin,
are equally capable of reducing blood loss. However,
the results were signicantly better than using oxytocin
alone in high-risk patients. Further studies in the future
are needed, especially in low-risk patients, due to the dis-
crepancy in the results of the previous studies.
Acknowledgements
None.
Authors’ contributions
O.H. and M.E. designed and supervised the study. M.D., M.A., and M.S.
conducted the study. M.A.R. analyzed the data. All authors wrote and
approved the manuscript.
Funding
This research received no specic grant from any funding agency.
Open access funding provided by The Science, Technology & Innovation
Funding Authority (STDF) in cooperation with The Egyptian Knowledge Bank
(EKB).
Data availability
The data that support the ndings of this study are available from Kasr El-Ainy
Hospital, but restrictions apply to the availability of these data, which were
used under license for the current study, and so are not publicly available.
Data are, however, available from the authors upon reasonable request and
with permission of Kasr El-Ainy Hospital.
Declarations
Ethical approval
The study protocol was approved by Kasr El-Ainy Ethical Committee. All
methods were carried out following the relevant guidelines and regulations.
Informed consent was obtained from all participants.
Clinical Trial Registration
The clinical trial was registered at www.clinicaltrials.govon07/10/2019 with
registration number NCT04117243.
Consent for publication
Not Applicable.
Informed consent
All participants gave their consent after being informed of the study’s
objective and design, and they were given the option to leave the study at
any time.
Competing interests
The authors declare no competing interests.
Received: 23 June 2022 / Accepted: 18 August 2023
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