We appreciate the interest in our article.1 We are well-aware of the limitations of the WOMAN trial and the fact that the benefit may not be as robust in developed nations. We clearly state the latter in the last paragraph of our article.
We do not recommend but suggest the use of tranexamic acid (TXA) in obstetric hemorrhage as a second-line agent, especially when there is no initial response to first-line treatments such as uterotonics. We do not recommend TXA as a first-line agent for the treatment of obstetric hemorrhage, and this is not mentioned anywhere in our article. Our suggestion as a second-line agent is in agreement with the latest recommendations from the American College of Obstetricians and Gynecologists and the World Health Organization.2,3 Our opinion is not based solely on the WOMAN trial, but also takes into account the evidence from smaller trials in pregnancy as well as larger trials in nonpregnant patients, as reviewed in our publication.
Butwick et al express concern that the Kruithof study4 analyzed the blood samples of only 10 women. We also are aware of this and included a second reference with more than 70 women with postpartum hemorrhage, demonstrating a significant increase in D-dimer levels,5 which was overlooked by the authors.
More data and well-designed studies to improve our understanding of the role of TXA in obstetric hemorrhage are always welcome. We encourage all investigators, including the authors of the letter, to perform these studies or report on their experience with TXA. However, we feel that withholding TXA from patients who are experiencing severe hemorrhage despite first-line agents would be irresponsible at this time.