Topical Tranexamic Acid to Reduce Blood Loss During Cesarean Delivery

Does Topical Use of Tranexamic Acid During a Cesarean Delivery Reduce Intra-surgical Bleeding? A Randomized ,Multi-center Trial

The goal of this clinical trial is to learn whether applying topical tranexamic acid (TXA) directly to the uterine incision during cesarean delivery can reduce surgical bleeding compared to placebo. The study will include pregnant women aged 18-51 undergoing elective cesarean delivery at term (37 weeks or more).

The main questions it aims to answer are:

• Does topical TXA shorten uterine closure time?
• Does topical TXA reduce the need for additional hemostatic sutures? Researchers will compare women receiving topical TXA to those receiving placebo (normal saline) to see if TXA reduces intraoperative bleeding and improves surgical outcomes.

Participants will:

• Be randomly assigned to receive either topical TXA or placebo during cesarean delivery.
• Have standard surgery and postoperative care identical in both groups.
• Provide routine clinical data, including hemoglobin levels and recovery outcomes, from their medical records.

Cesarean delivery carries a recognized risk of significant intraoperative bleeding despite standard uterotonic use and established surgical techniques. Tranexamic acid (TXA), an antifibrinolytic medication, reduces surgical blood loss when administered intravenously, but little is known about the effectiveness of topical TXA applied directly to the uterine incision during cesarean delivery. Evidence from other surgical fields suggests that topical TXA may reduce bleeding with minimal systemic absorption.

This study is a multi-center, randomized, placebo-controlled trial designed to evaluate whether topical TXA decreases intraoperative bleeding during elective cesarean delivery at term. A total of 112 participants will be randomized in a 1:1 ratio to receive either TXA (500 mg diluted in 15 mL saline) or an identical-appearing saline placebo. The study drug is applied by spraying the solution directly onto the uterine incision after placental delivery and before each layer of uterine closure. Randomization will be stratified by site, and allocation will be concealed using sequentially numbered envelopes opened by a scrub nurse.

All cesarean procedures will follow a standardized operative technique to minimize variability. Intraoperative and postoperative data will be collected from medical records, including operative characteristics, perioperative hemoglobin values, use of additional hemostatic measures, length of stay, and maternal or neonatal complications. Safety monitoring will focus on thromboembolic events, allergic reactions, and postoperative infections, with periodic review by an independent safety officer.

This trial aims to determine whether a localized, low-cost antifibrinolytic intervention can improve hemostasis during cesarean delivery and potentially be incorporated into routine surgical practice.

Inclusion Criteria:

• Women aged 18 to 51 years
• Singleton pregnancy
• Elective cesarean delivery scheduled at ≥37+0 weeks of gestation
• First or second cesarean delivery only
• Low transverse uterine incision planned
• Double-layer uterine closure using 1-0 Vicryl sutures
• Ability to provide written informed consent

Exclusion Criteria:

• Known allergy or hypersensitivity to tranexamic acid (TXA)
• History of bleeding or coagulation disorders
• Previous postpartum hemorrhage
• Placenta previa or placenta accreta spectrum
• Presence of uterine myomas
• Current use of anticoagulant or antiplatelet medications
• Planned or intraoperative conversion to general anesthesia
• Known uterine malformations
• Known bleeding tendency or thromboembolic disease