A Phase 2/3 interventional study of Tranexamic Acid and Placebo in Post Partum Hemorrhage, Fibrinolysis; Hemorrhage and Blood Loss, sponsored by University of Texas Southwestern Medical Center. Completed at 1 site in United States. Open to female participants aged 18 Years and older, including healthy volunteers. Per ClinicalTrials.gov, last updated 2021-01-19.
Sponsored by University of Texas Southwestern Medical Center · Phase 2/3, Interventional, and Prevention
The investigators prepared a novel study of tranexamic acid (TXA) designed to estimate the quantity of blood loss in women undergoing elective repeat cesarean deliveries. This is the first trial to utilize a prophylactic dose of TXA prior to incision followed by a subsequent prophylactic dose at placental delivery in obstetric patients undergoing scheduled cesareans. The purpose of this study is to quantify blood loss during uncomplicated repeat cesarean deliveries with and without TXA. The central hypothesis is that TXA administration reduces blood loss and fibrinolysis in women undergoing repeat cesarean sections.
Obstetric hemorrhage has been identified as a contributory cause for the United States' suboptimal and inequitable outcomes among pregnant women. As such, obstetric hemorrhage has become a formal focus point in a national agenda to improve maternal outcomes. Strategies to identify maternal hypovolemia and treating obstetric hemorrhage are undergoing organized scrutiny in many states including Texas. Tranexamic acid (TXA) treatment is receiving increased emphasis in obstetric care because TXA inhibits fibrinolysis. Increased clot stability offers the possibility of preventing blood loss (prophylaxis) as well as mitigating ongoing hemorrhage. TXA therapy has been principally studied in nonpregnant populations; results of studies in pregnant women have been lacking.
Tranexamic acid is an antifibrinolytic agent that acts as a competitive inhibitor at the lysine binding sites of plasminogen and inhibits the ability of protease plasmin to cleave the fibrin clot. In large randomized controlled trials, it has been reported to be effective in decreasing perioperative blood loss in a variety of circumstances primarily involving trauma patients. Shakur and co-authors in a trial of 20,000 non-pregnant trauma patients reported a significant reduction in all-cause mortality after TXA administration. In another large study (WOMAN Trial), 20,000 pregnant women with hemorrhage were randomized to TXA or placebo. TXA was associated with a significant decrease in death due to bleeding.
Tranexamic acid's role in treating hemorrhage have been widely studied in non-pregnant populations. Studies of TXA in obstetrics are limited. The American College of Obstetricians and Gynecologists believes the data is insufficient to recommend tranexamic acid for prophylaxis.
The investigators designed a randomized placebo-controlled trial comparing TXA dosing prior to incision for cesarean delivery with a repeat dose given at placental delivery. The purpose is to quantify blood loss during uncomplicated repeat cesarean deliveries with and without TXA. The investigators elected to study scheduled elective cesareans because such procedures are at low risk for profound hemorrhage. It is the intent to have a study cohort where the two treatment groups (TXA or placebo) are as comparable as possible, so the efficacy of TXA is not tested in women with highly variable volumes of obstetric hemorrhage.
445 studies on the registry are indexed under Postpartum Hemorrhage; 75 are open to participants now.
This study's enrollment of 110 is below the median of 148 across 340 interventional studies indexed under Postpartum Hemorrhage.
Browse Postpartum Hemorrhage studies →University of Texas Southwestern Medical Center is the lead sponsor of 990 studies on the registry; 201 are open to participants now.
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Exclusion Criteria:
Tranexamic Acid for intravenous administration.
Drug: Tranexamic Acid
Normal saline for intravenous administration.
Drug: Placebo
Two doses of Tranexamic Acid (1 gram), diluted in 100 cc of normal saline. Administered intravenously at least 10 minutes prior to skin incision and repeated immediately after placental delivery.
Also known as: Cyklokapron
100 mL of normal saline. Administered intravenously at least 10 minutes prior to skin incision and repeated immediately after placental delivery.
Also known as: Normal Saline
Blood Volume Loss
Total blood volume loss will be calculated in milliliters.
Time frame: 24 hours postpartum.
D-Dimer (µg/mL)
Measured from blood sample collection.
Time frame: Collection prior to first drug infusion, immediately before second infusion and 24 hours postpartum.
Fibrinogen (mg/dL)
Measured from blood sample collection.
Time frame: Collection prior to first drug infusion, immediately before second infusion and 24 hours postpartum.
Tissue Plasminogen Activator Antigen (ng/mL)
Measured from blood sample collection.
Time frame: Collection prior to first drug infusion, immediately before second infusion and 24 hours postpartum.
Plasminogen Activator Inhibitor-Type-1 (Units/mL)
Measured from blood sample collection.
Time frame: Collection prior to first drug infusion, immediately before second infusion and 24 hours postpartum.
Rotational Thromboelastometry INTEM and EXTEM Clotting Time
Rotational thromboelastometry is a whole blood viscoelastic test that analyzes deficits in clotting factors, clot strength, and clot breakdown. EXTEM, INTEM, and FIBTEM tests measure the extrinsic pathway, intrinsic pathway, and fibrinogen levels, respectively. Compared to non-pregnant patients, FIBTEM/EXTEM/INTEM amplitudes and the FIBTEM maximum clot firmness are higher in pregnant women. The EXTEM and INTEM clotting time are shorter, indicating the relative hypercoagulability of pregnancy. Reference ranges for INTEM Clotting Time (100-240 seconds), INTEM Maximum Clot Firmness (50-72 millimeter), EXTEM Clotting Time (38-79 seconds), EXTEM Maximum Clot Firmness (50-72 millimeter), FIBTEM Maximum Clot Firmness (9-25 millimeter).
Time frame: Collection prior to first drug infusion, immediately before second infusion and 24 hours postpartum.
Rotational Thromboelastometry INTEM, EXTEM, FIBTEM Maximum Clot Firmness
Rotational thromboelastometry is a whole blood viscoelastic test that analyzes deficits in clotting factors, clot strength, and clot breakdown. EXTEM, INTEM, and FIBTEM tests measure the extrinsic pathway, intrinsic pathway, and fibrinogen levels, respectively. Compared to non-pregnant patients, FIBTEM/EXTEM/INTEM amplitudes and the FIBTEM maximum clot firmness are higher in pregnant women. The EXTEM and INTEM clotting time are shorter, indicating the relative hypercoagulability of pregnancy. Reference ranges for INTEM Clotting Time (100-240 seconds), INTEM Maximum Clot Firmness (50-72 millimeter), EXTEM Clotting Time (38-79 seconds), EXTEM Maximum Clot Firmness (50-72 millimeter), FIBTEM Maximum Clot Firmness (9-25 millimeter).
Time frame: Collection prior to first drug infusion, immediately before second infusion and 24 hours postpartum.
Participants were recruited based on admission for delivery at an academic center between June 2019 and January 2020. The first participant was enrolled on June 17, 2019, and the last participant was enrolled on January 10, 2020.
| Milestone | Tranexamic Acid | Placebo |
|---|---|---|
| Started | 55 | 55 |
| Completed | 55 | 55 |
| Not completed | 0 | 0 |
Total blood volume loss will be calculated in milliliters.
| milliliters | Tranexamic Acid | Placebo |
|---|---|---|
| Blood Volume Loss | 2274 ± 469 | 2407 ± 388 |
Measured from blood sample collection.
| µg/mL | Tranexamic Acid | Placebo |
|---|---|---|
| Before Surgery | 2.9 ± 1.5 | 4.0 ± 5.3 |
| After Delivery | 2.4 ± 1.3 | 3.8 ± 4.7 |
| P.O.D. 1 | 2.1 ± 1.2 | 4.3 ± 2.4 |
Measured from blood sample collection.
| mg/dL | Tranexamic Acid | Placebo |
|---|---|---|
| Before Surgery | 563.5 ± 83.9 | 550.7 ± 68.2 |
| After Delivery | 499.6 ± 77 | 484.9 ± 82.5 |
| P.O.D. 1 | 527.4 ± 69.8 | 525.4 ± 86.1 |
Measured from blood sample collection.
| ng/mL | Tranexamic Acid | Placebo |
|---|---|---|
| Before Surgery | 8.1 ± 3.6 | 8.2 ± 2.7 |
| After Delivery | 9.0 ± 3.7 | 9.6 ± 2.9 |
| P.O.D. 1 | 7.5 ± 3.7 | 7.4 ± 3.3 |
Measured from blood sample collection.
| IU/mL | Tranexamic Acid | Placebo |
|---|---|---|
| Before Surgery | 81.8 ± 34.7 | 61.7 ± 33.8 |
| After Delivery | 67.0 ± 32.3 | 63.3 ± 31.9 |
| P.O.D. 1 | 20.7 ± 26.7 | 22.1 ± 28.5 |
Rotational thromboelastometry is a whole blood viscoelastic test that analyzes deficits in clotting factors, clot strength, and clot breakdown. EXTEM, INTEM, and FIBTEM tests measure the extrinsic pathway, intrinsic pathway, and fibrinogen levels, respectively. Compared to non-pregnant patients, FIBTEM/EXTEM/INTEM amplitudes and the FIBTEM maximum clot firmness are higher in pregnant women. The EXTEM and INTEM clotting time are shorter, indicating the relative hypercoagulability of pregnancy. Reference ranges for INTEM Clotting Time (100-240 seconds), INTEM Maximum Clot Firmness (50-72 millimeter), EXTEM Clotting Time (38-79 seconds), EXTEM Maximum Clot Firmness (50-72 millimeter), FIBTEM Maximum Clot Firmness (9-25 millimeter).
| seconds | Tranexamic Acid | Placebo |
|---|---|---|
| Before Surgery INTEM Clotting Time | 149.7 ± 14.4 | 150.5 ± 14.2 |
| After Delivery INTEM Clotting Time | 137.4 ± 18.3 | 140.7 ± 29.9 |
| P.O.D. 1 INTEM Clotting Time | 145.1 ± 16.3 | 141.2 ± 16.4 |
| Before Surgery EXTEM Clotting Time | 54.0 ± 5.1 | 56.1 ± 7.2 |
| After Delivery EXTEM Clotting Time | 54.9 ± 6.3 | 56.3 ± 8.0 |
| P.O.D. 1 EXTEM Clotting Time | 49.3 ± 5.3 | 50.2 ± 6.9 |
Rotational thromboelastometry is a whole blood viscoelastic test that analyzes deficits in clotting factors, clot strength, and clot breakdown. EXTEM, INTEM, and FIBTEM tests measure the extrinsic pathway, intrinsic pathway, and fibrinogen levels, respectively. Compared to non-pregnant patients, FIBTEM/EXTEM/INTEM amplitudes and the FIBTEM maximum clot firmness are higher in pregnant women. The EXTEM and INTEM clotting time are shorter, indicating the relative hypercoagulability of pregnancy. Reference ranges for INTEM Clotting Time (100-240 seconds), INTEM Maximum Clot Firmness (50-72 millimeter), EXTEM Clotting Time (38-79 seconds), EXTEM Maximum Clot Firmness (50-72 millimeter), FIBTEM Maximum Clot Firmness (9-25 millimeter).
| millimeter | Tranexamic Acid | Placebo |
|---|---|---|
| Before Surgery INTEM Maximum Clot Firmness | 69.3 ± 3.3 | 69.4 ± 3.7 |
| After Delivery INTEM Maximum Clot Firmness | 68.9 ± 3.2 | 68.4 ± 5.5 |
| P.O.D. 1 INTEM Maximum Clot Firmness | 68.8 ± 3.1 | 68.8 ± 3.8 |
| Before Surgery EXTEM Maximum Clot Firmness | 70.8 ± 3.1 | 71.2 ± 3.5 |
| After Delivery EXTEM Maximum Clot Firmness | 69.8 ± 3.1 | 69.6 ± 5.5 |
| P.O.D. 1 EXTEM Maximum Clot Firmness | 70.5 ± 2.8 | 70.4 ± 4.0 |
| Before Surgery FIBTEM Maximum Clot Firmness | 24.2 ± 3.8 | 23.9 ± 4.8 |
| After Delivery FIBTEM Maximum Clot Firmness | 22.5 ± 4.1 | 22.0 ± 4.4 |
| P.O.D. 1 FIBTEM Maximum Clot Firmness | 25.8 ± 4.7 | 25.0 ± 5.0 |
Collected over During patient admission, minimum of 3 days.. Non-serious events are listed at a 0% frequency threshold.
| Group | Deaths | Serious | Other |
|---|---|---|---|
| Tranexamic Acid | 0/55 (0%) | 0/55 (0%) | — |
| Placebo | 0/55 (0%) | 0/55 (0%) | — |
| Age, Continuous(years) | Tranexamic Acid | Placebo | Total |
|---|---|---|---|
| Mean | 29.8 ± 5.2 | 28.7 ± 5.2 | 29.3 ± 5.2 |
| Sex: Female, Male(Participants) | Tranexamic Acid | Placebo | Total |
|---|---|---|---|
| Female | 55 | 55 | 110 |
| Male | 0 | 0 | 0 |
| Race/Ethnicity, Customized(Participants) | Tranexamic Acid | Placebo | Total |
|---|---|---|---|
| Black, non-Hispanic | 1 | 9 | 10 |
| White, non-Hispanic | 2 | 0 | 2 |
| Hispanic | 52 | 46 | 98 |
| Region of Enrollment(participants) | Tranexamic Acid | Placebo | Total |
|---|---|---|---|
| United States | 55 | 55 | 110 |
| Parity(Participants) | Tranexamic Acid | Placebo | Total |
|---|---|---|---|
| Parity = 1 | 26 | 23 | 49 |
| Parity = 2 | 26 | 27 | 53 |
| Parity = 3 | 1 | 3 | 4 |
| Parity = 4 | 1 | 2 | 3 |
| Parity = 5 | 1 | 0 | 1 |
| Body Mass Index (kg/m^2)(Participants) | Tranexamic Acid | Placebo | Total |
|---|---|---|---|
| < 25 | 1 | 3 | 4 |
| 25 - < 30 | 17 | 16 | 33 |
| 30 - < 35 | 17 | 16 | 33 |
| 35 - < 40 | 10 | 13 | 23 |
| > =40 | 10 | 7 | 17 |
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University of Texas Southwestern Medical Center