Ruptured Ectopic and Tranexamic Acid
Date First Published:
February 12, 2020
Last Updated:
February 12, 2020
Report by:
Beth Renwick, FY2 Doctor (Manchester University Foundation NHS Trust, Manchester, UK)
Search checked by:
Alan Grayson, Manchester University Foundation NHS Trust, Manchester, UK
Three-Part Question:
In [a woman presented with a ruptured ectopic pregnancy] is [tranexamic acid better than placebo] at [reducing mortality]?
Clinical Scenario:
The Royal College of Obstetricians and Gynaecologists (1) reports that 11 pregnancies per 1000 are ectopic and that the maternal mortality rate from ectopic pregnancy is 0.2 per 1000. The Healthcare Safety Investigation Branch (2) found of the 12 maternal deaths in early pregnancy in the UK between 2009-14, 9 were related to ectopic pregnancy.
Search Strategy:
Medline 1966-09/2019 using PubMed and Cochrane Library 2019 ectopic pregnancy OR ductal pregnancy OR pregnancy of unknown location OR tubal pregnancy AND tranexamic acid. Limit to English language.
Outcome:
10 Papers identified. 1 conference summary, 5 unsuitable publications (Danish GP practice guidelines, 1966 paper with abstract not available, 3 publications unrelated to ectopic pregnancy), 4 case reports where tranexamic used in management of ectopic pregnancy.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Cervical ectopic pregnancy managed with methotrexate and tranexamic acid: A case report. Arowojolu AO, Ogunbode OO. 2014, | 29 yr old – live cervical pregnancy | Case Report | Live cervical pregnancy treated successfully with IM methotrexate and tranexamic acid followed by suction evacuation with balloon tamponade | TXA used in conjunction with other medical and surgical interventions Patient survived | Case Report |
| Jehovah’s Witness patients presenting with ruptured ectopic pregnancies: two case reports. Murphy NC, Hayes NE, Ainle FBN et al, 2014, | 34 yr old – ruptured ectopic pregnancy | Case Report | 1g IV tranexamic acid during right-sided salpingectomy | TXA used in conjunction with surgical intervention Patient survived | Case Report |
| Management of pregnancy for a patient with the new syndromic macrothrombocytopenia, DIAPH1-related disease. Nurden P, Nurden A, Favier R et al. 2018 | Unknown age female with ectopic pregnancy | Case Report | Underwent surgery for ectopic pregnancy, tranexamic acid used intra operatively | TXA used in conjunction with other surgical interventions No adverse outcomes reported Patient survived | Case Report<br><br>Unable to access full text |
| Management of severe bleeding in a ruptured extrauterine pregnancy: a theragnostic approach. Grassetto A, Fullin G, Cerri G et al. 2014, | 37 yr old – ruptured ectopic pregnancy | Case Report | Emergency laparotomy, RBC transfusion and haemostatic therapy. <br><br>Severe hypofibrinogenaemia was present and treated with 4 g fibrinogen concentrate plus 1 g TXA | TXA used in conjunction with other medical and surgical interventions<br><br>Patient survived | Case Report |
Author Commentary:
The available evidence for the use of tranexamic acid in management of ruptured ectopic pregnancy is weak and none of the available papers answer the question proposed above. However, the case reports do not put forward any adverse outcomes when using tranexamic acid in conjunction with other management options.<br><br>There is robust evidence for the use of tranexamic acid in other comparable patient populations. The 2013 CRASH 2 trial (3)found Tranexamic acid safely reduced the risk of death in bleeding trauma patients, the 2017 WOMAN trial (4)found tranexamic acid significantly reduced death due to bleeding in patients with PPH and a 2018 review found the use of tranexamic acid significantly reduced blood loss in women undergoing caesarean section.
Bottom Line:
There is no evidence to suggest the use of tranexamic acid increases that rate of adverse outcomes and no patient mortality was reported within the available case studies.<br><br>Strong evidence is available to support the use of tranexamic acid in bleeding trauma patients within the emergency department, in post-partum haemorrhage and in those undergoing caesarean section. There is therefore significant overlap in the patient populations where tranexamic acid is effective and it is therefore reasonable to treat haemorrhage due to ruptured ectopic pregnancy in a similar way.
References:
- [No authors listed]. Diagnosis and Management of Ectopic Pregnancy (Green-top Guideline No. 21).
- Healthcare Safety Investigation Branch [HSIB]. . The Diagnosis of Ectopic Pregnancy.
- Arowojolu AO, Ogunbode OO. . Cervical ectopic pregnancy managed with methotrexate and tranexamic acid: A case report.
- Murphy NC, Hayes NE, Ainle FBN et al,. Jehovah’s Witness patients presenting with ruptured ectopic pregnancies: two case reports.
- Nurden P, Nurden A, Favier R et al.. Management of pregnancy for a patient with the new syndromic macrothrombocytopenia, DIAPH1-related disease.
- Roberts I, Shakur H, Coats T et al.. The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients.
- WOMAN Trial Collaborators. . Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN):
- Franchini M, Mengoli C, Cruciani M et al.. Safety and efficacy of tranexamic acid for prevention of obstetric haemorrhage: An updated systematic review and meta-analysis.
- Grassetto A, Fullin G, Cerri G et al.. Management of severe bleeding in a ruptured extrauterine pregnancy: a theragnostic approach.