Last reviewed: June 2018
Last updated: February  2018

Antifibrinolytic treatment in acute severe hemorrhage must be immediate for maximum survival benefit

Treatment with an antifibrinolytic such as tranexamic acid is known to reduce death from bleeding in patients with trauma and post-partum hemorrhage. Now a new meta-analysis has found strong evidence that even a short delay in treatment reduces the survival benefit from tranexamic acid administration. The data, based on more than 40,000 patients with traumatic or post-partum bleeding, showed:

  • immediate treatment with tranexamic acid improved survival by more than 70% compared with placebo.

  • the survival benefit from tranexamic acid decreased by about 10% for every 15 minutes of treatment delay up until 3 hours, after which there was no benefit.

See Management: approach See Management: treatment algorithm

Original source of update



History and exam

Key diagnostic factors

  • scarred uterus
  • painless vaginal bleeding
  • absence of cervical/vaginal causes of bleeding on speculum examination

Other diagnostic factors

  • previous ultrasound anomaly in first trimester
  • lack of uterine tenderness
  • low BP and tachycardia

Risk factors

  • advanced maternal age
  • multiple previous pregnancies
  • smoking
  • uterine scarring (most commonly due to prior cesarean section)
  • infertility treatments
  • previous miscarriage
  • previous induced abortion
  • prior placenta previa
  • other placental abnormalities
  • short interpregnancy intervals
  • illicit drug use

Diagnostic investigations

1st investigations to order

  • uterine ultrasound with color flow Doppler analysis
  • CBC
  • type and crossmatch
Full details

Investigations to consider

  • MRI placenta
  • INR/PTT, fibrinogen, and fibrinogen degradation products
  • Kleihauer-Betke test
Full details

Treatment algorithm


Authors VIEW ALL

Janet R. Albers


Department Chair

Family and Community Medicine

Southern Illinois University School of Medicine




JRA has acted as an expert witness for the US Dept of Justice. JRA has received an honorarium for the development of learning material for Social Determinants of Health and Care Coordination for Relias Learning.


Clinical Family and Community Medicine

Residency Program Director

SIU Quincy Family Medicine

Southern Illinois University




THM declares that he has no competing interests.

Dr Janet R. Albers and Dr Thomas H. Miller would like to gratefully acknowledge Dr Robert Ewart and Dr Matthew Hagermeyer, previous contributors to this monograph. RE and MH declare that they have no competing interests.

Peer reviewers VIEW ALL

Assistant Professor

Head of Department of Obstetrics and Gynecology

Mosul College of Medicine




YTJ declares that he has no competing interests.

Consultant in Family Medicine

Parker D Sanders and Isabella Sanders Professor of Primary Care




JB declares that he has no competing interests.

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