Prophylactic tranexamic acid reduces severe bleeding after caesarean births

Researchers in China have shown that administering tranexamic acid to women with placenta praevia resulted in a significant reduction in severe postpartum bleeding and at the same time there was no indication of a rise in serious adverse events. [BMJ 2026;393:e089636] The new study adds high-quality evidence on the advantages of tranexamic acid for women with high-risk pregnancies.

Tranexamic acid inhibits the breakdown of blood clots and is recommended for the treatment of severe postpartum haemorrhage. It is also widely used to stop or reduce severe bleeding following surgery or trauma. However, its prophylactic use in postpartum haemorrhage among high-risk women lacks high-quality evidence. Thus, the researchers decided to take a closer look at a specific high-risk group: women with placenta praevia, as they are prone to severe bleeding.

The study recruited 1,694 pregnant women with placenta praevia who were booked for caesarean section at 24 maternity units throughout China from July 2023 to March 2025. The women received prophylactic oxytocin, a standard treatment for preventing excessive postpartum blood loss, and were randomised to receive either intravenous tranexamic acid (n=845) or placebo (n=849) for 10 minutes. Administration of tranexamic acid or placebo was within 5 minutes after the placenta was clamped.

The key outcome measure was postpartum haemorrhage, defined as blood loss of 1,000 mL or more, or blood transfusion within 2 days after delivery. Serious adverse events reported included blood clots, seizures, acute kidney or liver injury, and maternal death.

The findings showed that prophylactic tranexamic acid reduced the rate of postpartum haemorrhage by 15 percent. The primary outcome occurred in 29.7 percent of the tranexamic acid group, compared with 35.1 percent of the placebo group.

This equates to one case of postpartum haemorrhage prevented for every 19 women receiving prophylactic tranexamic acid. Furthermore, the rates of serious adverse effects were similar between the tranexamic acid and placebo groups.

The study was well planned, and the results remained consistent after additional scrutiny, demonstrating the strength of the findings. Nevertheless, the researchers noted several limitations, including that the findings apply specifically to women with placenta praevia receiving prophylactic oxytocin and therefore, may not be applicable to other obstetric groups.

Therefore, the researchers concluded: “In a high-risk population—specifically, women with placenta praevia undergoing caesarean delivery—prophylactic tranexamic acid leads to a statistically significant but modest reduction in the incidence of postpartum haemorrhage.”

“Future studies in diverse international settings are warranted to validate these results and identify the specific patient subgroups most likely to benefit from prophylactic use of tranexamic acid,” they added.

In an accompanying editorial, researchers in the UK noted that this modest decrease in bleeding underemphasises the effect, especially among women vulnerable to harm from bleeding, for whom even modest relative risk reductions can result in meaningful benefits. [BMJ 2026;393:s818]

The focus should now shift from whether tranexamic acid reduces bleeding to how best to use it to achieve maximum patient benefit, they wrote. They pointed out that in non-obstetric surgery, tranexamic acid is administered before incision, whereas in caesarean section trials it is delayed until after the cord is clamped to prevent placental transfer.