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.