During the 2019 ISTH Opening Ceremony, Prof. Beverley Hunt brought to light an underrecognized and widespread global problem, postpartum hemorrhage. She began the session by saying, “postpartum hemorrhage is a huge global problem in which one woman dies every 4 minutes and accounts for one in every 200 deaths globally.” The consequences of this problem extend beyond the mother, with surviving children having an earlier mortality rate, malnourishment, as well as, a higher probability of reduced schooling. She described this problem as a “human rights issue” and a “tragedy the ISTH community needs to focus on with research.”
Postpartum hemorrhage (PPH) is described as an excessive blood loss after child birth. The primary causes of PPH include uterine atony, surgical trauma and placenta praevia. There are several simple interventions that can be employed to prevent PPH, including optimization of hemoglobin early in pregnancy, identification of high-risk antenatal cases, active management of the third stage of labor, and use of uterotonics. One of the biggest challenges in low income countries is under development of blood donor and transfusion services needed to supply the critically needed units of blood in these urgent situations.
Dr. Hunt provided commentary on a critical trial in the field, the WOMAN study. This study evaluated the effect of tranexamic acid (TXA) on postpartum related mortality, need for hysterectomy and/or other surgical interventions, and thromboembolic events in over 20,000 patients with post partum haemorrhage enrolled at nearly 200 hospitals worldwide. Results showed that early administration of TXA reduced the cause of death due to bleeding by one third without increasing venous or arterial thrombotic events. Importantly, the survival benefit decreased by 10% for every 15 min delay until 3 hours, after which there was no benefit. This stresses the importance of early administration. This important piece of evidence led to the endorsement of the provision of intravenous TXA within 3 hours by the World Health Organization.
Prof. Hunt went on to describe the follow up study, WOMAN 2, is now currently enrolling patients, which started in March of 2019.
She concluded her presentation by discussing the future of hemostasis and PPH and suggested that the WOMAN study showed the possibilities of performing meaningful research in the area of obstetric hemorrhage. Now is the time to start a major international effort to improve care of patients with PPH similar to the attention given to traumatic coagulopathy over the last 10 years. She left the audience with 3 key points: 1. A request to the ISTH community to look towards translational research in PPH, 2. The need to make blood available for patients with PPH, in low- and middle-income countries, and 3. That TXA should be made available and used in appropriate patients with PPH.