Prophylactic use of tranexamic acid to prevent postpartum hemorrhage in high-risk cesarean deliveries: a systematic review and meta-analysis

Background . Postpartum hemorrhage is a leading cause of maternal morbidity and mortality worldwide, particularly among high-risk women. Tranexamic acid has been used as prophylaxis for postoperative blood loss. This systematic review and meta-analysis evaluated the efficacy and safety of tranexamic acid in preventing postpartum hemorrhage in cesarean sections in high-risk women. Methods . A systematic review with meta-analysis was performed. The risk of bias was assessed using RoB 2.0. Meta-analyses were performed using a random-effects model, along with subgroup and sensitivity analyses. The GRADE methodology was used to assess the certainty of the evidence. Results . Ten randomized controlled trials involving 1,811 participants were included. Tranexamic acid substantially reduced total blood loss (SMD = -1.74; 95% CI -3.09 to -0.39), with optimal efficacy when administered 15–20 minutes before incision (SMD = -0.61; 95% CI -0.82 to -0.39). Intraoperative blood loss (SMD = -0.99; 95% CI -1.15 to -0.82), blood loss at two hours (SMD = -0.78; 95% CI -1.21 to -0.35), and blood loss >1000 mL (RR = 0.24; 95% CI 0.14 to 0.41) were also reduced. Hematological outcomes, need for additional uterotonics (RR = 0.37; 95% CI 0.24 to 0.58), blood transfusions (RR = 0.30; 95% CI 0.22 to 0.40), and complementary surgical interventions (RR = 0.35; 95% CI 0.16 to 0.78) were likely reduced. Conclusions . Tranexamic acid as a prophylactic intervention effectively reduces blood loss in high-risk cesarean sections, particularly when administered 15–20 minutes before skin incision. It decreases total and intraoperative blood loss, blood loss at two hours, and cases exceeding 1000 mL. Tranexamic acid also likely reduces postoperative hemoglobin and hematocrit drops, the need for additional uterotonics, blood transfusions, and complementary surgical interventions. Trial registration. PROSPERO CRD420251087054.