Tranexamic Acid at Cesarean Delivery: Drug-error Deaths

Abstract

(Am J Obstet Gynecol. 2023;228:1–4) Tranexamic acid plays an important role in reducing bleeding experienced during postpartum hemorrhage. It is recommended by the World Health Organization that tranexamic acid is administered intravenously, over 10 minutes, within 3 hours of delivery to treat postpartum hemorrhage. However, tranexamic acid, although helpful in cases of postpartum hemorrhage, has caused other problems to arise. It has been found that tranexamic acid is toxic when administered intrathecally (IT). Tranexamic acid has components that are known to lead to neuronal excitation when mistakenly administered in the intrathecal space. This most often leads to generalized convulsions and malignant arrhythmias. This has been occurring more frequently secondary to tranexamic acid being stored in labor and delivery operating rooms on anesthetic drug carts for easy access for hemorrhage during cesarean delivery. Both tranexamic acid and the drugs used for spinal anesthesia are stored in look-alike glass vials making this risk even more likely. A review published in 2019 reported 21 cases of inadvertent intrathecal administration of tranexamic acid, 20 of these cases were life-threatening with ten resulting in patient deaths. The accidental administration of tranexamic acid intrathecally most likely occurs more often than it has been reported. The mistake of replacing spinal anesthesia drugs with tranexamic acid most commonly occurs in small hospitals and low-middle-income countries.