DISCUSSION
This survey is the first to our knowledge that seeks to determine use of
TXA in clinical practice, elicit concerns and comfortability with use
among obstetricians and gynecologists. Although TXA was most often used
during a PPH, 52% of responders were only utilizing it < 10%
of the time or not at all. This finding reveals the unexpected
underutilization of TXA during PPH8. Given the WHO
recommendations regarding incorporation of TXA into the standard
postpartum hemorrhage protocol for vaginal and cesarean
sections9, we expected to see a higher utilization of
TXA in standard practice for PPH. The main issues with TXA use found in
this study are: concerns for thromboembolic events, lack of familiarity,
and a preference for other agents. As discussed previously, in review of
the current research, adverse events were not seen with use of TXA for
PPH. TXA is both cost-effective and efficient.
This study illustrates an association between increase use of TXA when
it is incorporated into a hospital protocol for PPH. When the hospital
had TXA as part of its PPH protocol, 86% of providers used TXA for PPH.
This finding suggests that to an individual provider, recognition of the
safety and effectiveness of TXA is more impactful at the local level
than it is on a global level. Plainly stated, individual hospital
protocols carry more weight than the World Health Organization to an
individual obstetrician in practice. Interestingly, although the major
concern with TXA use was increased risk of a thromboembolic event, an
overwhelming number of respondents would support incorporating TXA into
their hospital’s protocols. This finding is a little more elusive, but
may suggest that physicians might feel an added element of safety when
using a treatment that is perceived to be controversial if its use is
supported by their own hospital.
The survey has several limitations. The response rate of 27% is low and
may lead to unrecognized bias in the results. Also, there may be
selection bias as the majority of respondents were generalist and MFM
physicians, which may have skewed the results toward use during
obstetrical settings. In order to not burden respondents, the survey was
kept short with 10 questions; this may have led to challenges to
ascertain practice patterns of TXA use. Although the questions were
carefully selected, it may have been pertinent to include questions
about what motivated use of TXA. It would be interesting to compare use
before and after WOMAN trial. Furthermore, it would be interesting to
determine if changing hospital protocols is necessary for increased use
versus if increase use happens due to new data and large outside
influence. One explanation for greater use during obstetrics than
gynecology may be the WOMEN trial and recent WHO recommendations for use
during PPH.
Disclosure of Interest: No conflicts of interest or
disclosures.
Contribution of authorship: RBD was instrumental in creating
and distributing the survey as well as data collection and writing. ML
played an active role in the development of the survey and the editing
of the manuscript. SN, CH, LM assisted in the development of the survey
and the data analysis. JG assisted in the writing of the manuscript and
the editing.
Details of ethics approval: The project was reviewed by the
Institutional Review Board and approved on 12/22/2017. The final
approval was by Stephanie Sima Ortel at Loyola University Medical
Center. Project LU# 210587.
Funding: No funding was use for this project.