(1191) Prophylactic TXA prior to skin incision in high-risk cesarean deliveries: Does it make a difference?

The objective of this study was to evaluate the implementation and impact of a quality improvement (QI) protocol focused on prophylactic tranexamic acid (TXA) administration prior to skin incision in cesarean deliveries (CD) at high-risk for postpartum hemorrhage (PPH).

Study Design:

We undertook a QI initiative centered on prophylactic TXA given prior to skin incision in CDs at medium to high risk for PPH. We evaluated perioperative outcomes in 2 successive cohorts – 3 months before and after implementation, from November 2022 to April 2023. Our protocol entailed: 1 gm IV infusion 10 minutes prior to skin incision in CDs with no contraindications to TXA. Demographic characteristics and perioperative outcomes were abstracted from electronic records and compared across the 2 groups using Student’s t-test and c² or Fischer’s exact test for continuous and categorical data, respectively. Statistical significance was set at p≤.05. Our primary implementation outcome was % of eligible CDs receiving prophylactic TXA per protocol and primary effectiveness outcomes were quantitative blood loss (QBL) and need for transfusion.

Results:

250 patients were included in this analysis: 125 each, pre and post-implementation. Demographic characteristics were similar across both groups, including BMI, number of prior CDs, type of anesthesia, uterine incision, timing, type and duration of CD, and gestational age at delivery. Of all eligible patients, 62.1% (n=72) in the pre- and 90.4% (n=103) in the post-implementation group received TXA per protocol (p< .01). QBL was similar across groups; however, the post-implementation group had lower rates of transfusion, including number of packed red blood cells (PRBC), total units transfused, and cases requiring >2 units PRBC, which trended towards significance (p=.07). Changes in hemoglobin, need for additional uterotonic agents, and arterial embolization/cesarean hysterectomy rates were similar.

Conclusion:

Prophylactic TXA administration may have limited clinical utility in high-risk CDs, however the optimal timing of administration and effectiveness needs further evaluation.