Postpartum haemorrhage remains one of the leading causes of maternal morbidity and mortality worldwide, particularly among women with high-risk obstetric conditions such as placenta praevia. A newly published phase 3 randomised controlled trial in The BMJ examined whether prophylactic tranexamic acid could reduce bleeding complications in women with placenta praevia undergoing caesarean delivery. The findings suggest that tranexamic acid may provide a clinically meaningful reduction in postpartum haemorrhage without increasing serious adverse events.
Placenta praevia occurs when the placenta partially or completely covers the cervical opening or implants in the lower uterine segment. This condition substantially increases the likelihood of severe bleeding during delivery, especially during caesarean section. The risk rises further when placenta accreta spectrum disorders coexist.
Although oxytocin remains standard prophylaxis against postpartum haemorrhage, clinicians continue to explore additional interventions for women considered at particularly high risk. Tranexamic acid, an antifibrinolytic agent that inhibits plasmin mediated clot breakdown, has already demonstrated benefit in treating established postpartum haemorrhage. However, evidence supporting routine preventive use in high risk obstetric populations has remained limited until now.
The multicentre trial enrolled 1,732 women with placenta praevia across 24 maternity units in China between July 2023 and March 2025. Participants undergoing caesarean delivery were randomised to receive either:
Both groups also received standard prophylactic oxytocin. The study drug was administered within five minutes after umbilical cord clamping.
Researchers used a double blind, placebo-controlled design, strengthening the reliability of the findings. The primary outcome was postpartum haemorrhage, defined as either:
Nearly 18% of participants also had placenta accreta spectrum disorders, making this a particularly high-risk cohort.
The study demonstrated a statistically significant reduction in postpartum haemorrhage among women who received prophylactic tranexamic acid.
This translated to a number needed to treat of 19 to prevent one case of postpartum haemorrhage.
Researchers also observed reductions in:
Although transfusion rates trended lower in the tranexamic acid arm, the difference did not reach statistical significance.
Importantly, serious adverse events were uncommon and similar between groups.
The incidence of:
did not differ meaningfully between treatment arms.
This finding is particularly relevant because concerns about thrombosis have historically influenced clinician caution regarding broader tranexamic acid use in obstetrics.
An accompanying editorial in The BMJ Editorial Section highlighted the clinical importance of reducing bleeding in women at elevated risk of maternal complications.
The editorial authors noted that even modest reductions in blood loss can significantly improve outcomes for women with underlying anaemia, which remains common globally. They also argued that future research should focus less on whether tranexamic acid works and more on how to optimise its use.
One unresolved issue involves timing of administration. In many surgical specialties, tranexamic acid is administered before incision. In obstetrics, however, administration is often delayed until after cord clamping because of concerns regarding placental transfer to the fetus.
The editorial suggests that future large-scale trials evaluating pre-incision administration in caesarean delivery may be warranted.
For healthcare professionals managing high-risk caesarean deliveries, these findings may support broader consideration of prophylactic tranexamic acid use in women with placenta praevia.
Several aspects strengthen the applicability of the study:
However, clinicians should interpret the results within context. The trial was conducted exclusively in China, and patient demographics, surgical practices, and transfusion protocols may differ across healthcare systems.
Additionally, while reductions in bleeding endpoints were statistically significant, the overall effect size was modest.
Previous trials such as TRAAP2 primarily evaluated lower-risk or mixed-risk caesarean populations. This newer BMJ study specifically targeted women with placenta praevia, a group known to have substantially elevated haemorrhage risk.
The results align with broader surgical literature showing that tranexamic acid can reduce perioperative blood loss across multiple surgical specialties.
Evidence from major surgical trials including ATACAS, POISE-3, and TRACTION also supports the haemostatic benefits of tranexamic acid in non-obstetric surgery.
Despite encouraging findings, several unanswered questions remain:
Further international trials will likely be needed before universal recommendations can be established.
This phase 3 BMJ trial provides important new evidence supporting prophylactic tranexamic acid use in women with placenta praevia undergoing caesarean delivery. The intervention reduced postpartum haemorrhage rates without increasing serious adverse events.
For obstetricians, maternal fetal medicine specialists, anaesthetists, and maternity care teams, the findings contribute to a growing body of evidence supporting targeted preventive strategies for severe obstetric bleeding.
As postpartum haemorrhage continues to represent a major global maternal health challenge, optimising the preventive role of tranexamic acid may become an increasingly important component of high-risk obstetric care.
Ker K, Roberts I. Tranexamic acid for preventing severe bleeding in caesarean births BMJ 2026; 393 :s818 doi:10.1136/bmj.s818
Zhang L, Bi S, Chen L, Du L, He F, Qiao Y et al. Prophylactic tranexamic acid for the prevention of postpartum haemorrhage in women with placenta praevia: multicentre, double blind, randomised, placebo controlled, phase 3 trial BMJ 2026; 393 :e089636 doi:10.1136/bmj-2026-089636
This article is intended for informational and educational purposes only and is designed for healthcare professionals. It does not constitute medical advice, diagnosis, or treatment recommendations. Clinical decisions should be based on individual patient assessment, institutional protocols, and current professional guidelines.
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