Postpartum hemorrhage (PPH), a fatal bleed after childbirth, has been plaguing maternal health practitioners from time immemorial. It contributes significantly to maternal mortality in Pakistan (178 of 100,000 women die each year of PPH), and causes 100,000 deaths globally every year. Though PPH is a global phenomenon and can affect pregnant women from all classes, races and ethnicities, death is more prevalent in low and middle income countries due to weak health care infrastructures. However, according to a recently-reported study, the use of a locally-manufactured, readily available, inexpensive drug can significantly reduce chances of a woman bleeding to death after childbirth.
The WOMAN Trial – short for Word Maternal Antifibrinolytic – is a large-scale randomised and controlled trial that began in 2010 to evaluate the effect of tranexamic acid on the risk of death after postpartum haemorrhage. The trial included 20,000 women from 193 hospitals and across 21 countries. The results showed that use of this drug reduces chances of a woman dying due to PPH by 31 percent.
Though the use of tranexamic acid for trauma and surgery is common (it reduces the risk of fatality by 10-15 %), its role in reducing mortality rates was not known until now. Deaths by PPH are more common in developing countries and it is in these places that this drug can be extremely useful since one dosage costs less than two dollars and can be administered by a nurse, midwife or a junior doctor.
“It can be given anywhere an intravenous injection can be administered,” explains Dr Rizwana Chaudhri, head of Gynaecology and Obstetrics Department at Holy Family Hospital. “Capsules are also present but cannot be given in emergency situations because early absorption is required.”
Usually, in case of a PPH, huge quantities of blood is required. “Sometimes seven to eight bottles are urgently needed,” says Dr Chaudhri. Though public hospitals have blood banks, the vital fluid is not easily available in small and private facilities. Here, blood is rationed carefully for fear of depletion and often relatives are asked to donate. “Blood should be available in all hospitals for emergency situations and its quality should be maintained. Thankfully, tranexamic acid reduces the chances of requiring blood or the need of surgery.”
The hemorrhage begins when naturally-formed blood clots begin to break. Tranexamic acid prevents these clots from breaking without any side effects. Dr Chaudhri says that during the trial, it was feared that the drug might result in deep vein thrombosis (DVT), which can be fatal. “However, the results of the trial did not show any such signs,” she says.
“The World Health Organization (WHO) currently advises that tranexamic acid may be used if other first line treatments fail,” says Haleema Shakur, one of the main authors of the study. “Their recommendation was based on the results of trials in trauma and surgery. However, the WOMAN trial shows that time is critical and early treatment is needed as soon as possible. The WHO has committed to changing their current recommendations on the basis of the WOMAN Trial results.”
Tranexamic acid is easily available in Pakistan and is manufactured locally by Hilton Pharmaceuticals. The drug can be stored anywhere, without the need for refrigeration. “The state should take immediate action to add this to the essential drug list in all gynaecology wards across the country,” urges Dr Chaudhri.