Audit on the role of Tranexamic acid (TXA) in Major Obstetric Haemorrhage – the unanswered questions that need addressing.

Background
The MBRRACE report examining maternal mortality demonstrated 16% of direct causes of maternal death were from major obstetric haemorrhage (MOH). Guidelines from the Association of Anaesthetists of Great Britain and Ireland (AAGBI), based on TXA use in trauma cases (CRASH2 trial), suggest giving TXA in all MOH ≥1000ml; however our local policy, like many others, does not yet specify when and how it should be administered.

The WOMEN trial is due to publish soon; hopefully answering these (plus many more) questions.

Methods
Through case note review, anonymised data on management and documentation of MOH >2L was collated in respect to when, why and how TXA was given. 

Although the Obstetric Anaesthetists Association (OAA) state MOH as blood loss ≥1.5L, local policy is ≥2L. 8 months of data was collected as MOH data is locally categorised by year.

As well as TXA dosing and timing, other factors thought to influence clinicians’ decisions to administer TXA are included.

Results and Discussion
A retrospective audit of our medium sized (4350 deliveries/yr) maternity unit reviewed 30 out of 31 cases of ≥2L MOH. 

TXA was given in 43% of cases; these demonstrated partial correlation with total blood loss.

83% of cases involved anaesthetic support. 68% of anaesthetic charts recorded total blood loss but none recorded incremental losses.  The causes of MOH was solely uterine atony in only 30% of cases; the remaining cases related to tissue, trauma or a combination of factors. 


	Total 	Activation of MOH protocol	Average blood loss (median + IQR)	TXA given	TXA given <30 mins	Requiring blood products
No. of cases	30	9	2.2L
(2.1-3.0L)	13	10	10

Without local policy in place this audit demonstrated only limited use of TXA with inconsistency in dosing and timing. This is understandable; prior to the CRASH trial all guidelines listed TXA as a medication of last resort. 

The WOMEN trial will hopefully answer many of our questions; however, in the mean time, updating and circulating our policy should promote earlier administration. Encouraging documentation of cumulative/incremental blood loss will encourage vigilance and enforcing activation of the ‘controlled’ major haemorrhage protocol could persuade doctors to be more proactive, rather than reactive.

Conclusions
We keenly await the results of the WOMEN trial; however, until such time, we will encourage a culture of thorough documentation and early, proactive medical management/optimisation in line with AAGBI recommendations.

Audit on the role of tranexamic acid (TXA) in major obstetric haemorrhage – the unanswered questions that need addressing