WOMAN Trial: Tranexamic Acid in Postpartum Hemorrhage

TXA within 3 hr of PPH cuts death from bleeding by ~30%.

Population

20,060 women with clinically diagnosed PPH after vaginal delivery or C-section, across 193 hospitals in 21 countries.

Intervention

TXA 1 g IV over 10 min, with a second 1 g if bleeding continued at 30 min.

Comparison

Matching placebo IV.

Outcome

Composite of death from bleeding OR hysterectomy within 42 days.

Massive double-blind RCT — both physicians and patients blinded. Recruited from low-, middle-, and high-income settings. Pragmatic enrollment criteria (clinical PPH diagnosis, no specific volume threshold).

• Death from bleeding: 1.5% TXA vs 1.9% placebo (RR 0.81, 95% CI 0.65-1.00, P=0.045).
• Effect concentrated in TXA given <3 hr from bleeding onset: RR 0.69 (P=0.008).
• TXA given >3 hr: no benefit.
• No increase in thromboembolic events (DVT, PE, stroke).
• No reduction in hysterectomy alone (already inevitable by the time PPH was identified).

Give TXA 1 g IV within 3 hr of PPH onset — universally adopted into ACOG, WHO, and international PPH guidelines. The therapeutic window is critical: every 15-min delay reduces benefit. Operationally: keep TXA stocked in OB units + Pyxis kits; activate as part of stage-1 PPH bundle (NOT delayed until uterotonics fail).

• 'Death from bleeding' is the only outcome that reached significance; all-cause mortality was similar between groups.
• Low- and middle-income contexts may have different baseline care — generalizability not perfect.
• Did not address PROPHYLACTIC TXA in routine C-section (TRAAP and TRAAP-2 addressed that — modest reduction in hemorrhage, no mortality benefit).

1. Is TXA part of your PPH first-line bundle alongside uterotonics, or held until later in escalation?
2. Should it be prophylactic at every C-section? Where does TRAAP-2 land you?
3. How do you handle the contraindication concern in patients with cortical vein thrombosis history (real or theoretical)?