WOMAN-PharmacoTXA trial: Study protocol for a randomised controlled trial to assess the pharmacokinetics and pharmacodynamics of intramuscular, intravenous and oral administration of tranexamic acid in women giving birth by caesarean section

Abstract

Background: Intravenous tranexamic acid (TXA) within 3 hours of birth significantly reduces death due to bleeding in women with postpartum haemorrhage (PPH). Most PPH deaths occur in the first hours after giving birth and treatment delay decreases survival. One barrier to rapid TXA treatment is the need for intravenous injection. Intramuscular injection and oral solution of TXA would be easier and faster to administer and would require less training. However, the pharmacokinetics (PK), pharmacodynamics and safety of TXA administered by different routes in pregnant women have not been established. The main aim of this study is to ascertain whether IM and oral solution of TXA will be absorbed at levels sufficient to inhibit fibrinolysis in pregnant women. Methods: WOMAN-PharmacoTXA is a prospective, randomised, open label trial to be conducted in Zambia and Pakistan. Adult women undergoing caesarean section with at least one risk factor for PPH will be included. Women will be randomised to receive one of the following about 1 hour prior to caesarean section: 1-gram TXA IV, 1-gram TXA IM, 4-grams TXA oral solution or no TXA. Randomisation will continue until 120 participants with at least six post randomisation PK samples are included. TXA concentration in maternal blood samples will be measured at baseline and at different time points during 24 hours after receipt of intervention. Blood TXA concentration will be measured from the umbilical cord and neonate. The primary endpoint is maternal blood TXA concentrations over time. Secondary outcomes include umbilical cord and neonate TXA concentration D-dimer concentration, blood loss and clinical diagnosis of PPH, injection site reactions and maternal and neonate adverse events. Discussion: The WOMAN-PharmacoTXA trial will provide important data on pharmacokinetics, pharmacodynamics and safety of TXA after IV, intramuscular and oral administration in women giving birth by caesarean section. Trial registration: ClincalTrials.gov, NCT04274335 (18/02/2020).

Innovations in the prevention and treatment of postpartum hemorrhage: Analysis of a novel medicines development pipeline database

“…The database was conceived as an ongoing, “living” database that will be regularly updated, and the potential of candidates will change to reflect advances in the field. For example, ongoing research investigating alternative routes of administration and formulations of tranexamic acid—such as the ongoing WOMAN‐PharmacoTXA trial—will likely warrant inclusion in future database updates 43 …”

“…For example, ongoing research investigating alternative routes of administration and formulations of tranexamic acid-such as the ongoing WOMAN-PharmacoTXA trial-will likely warrant inclusion in future database updates. 43 In conclusion, the research and development pipeline for new medicines to prevent and treat PPH is limited and lacking diversity.…”

Alternative routes to intravenous tranexamic acid for postpartum hemorrhage: A systematic search and narrative review

“…Recruitment for this trial is completed and data analysis is ongoing. Results are expected during the first quarter of 2022 31 …”

Improving Development of Drug Treatments for Pregnant Women and the Fetus

“…Conduct of pharmacologic studies in pregnant women on a global scale does not always translate into global changes in clinical care. The London School of Hygiene and Tropical Medicine Clinical Trials Unit conducted several studies of pharmacologic interventions in pregnant women to reduce morbidity and mortality associated with postpartum hemorrhage [ 38 – 40 ]. These studies are primarily being conducted in low- and middle-income countries (LMIC) given that this is where 99% of maternal mortality from hemorrhage at delivery occurs [ 41 ].…”