Introduction: Postpartum hemorrhage (PPH) is a leading cause of maternal mortality and morbidity worldwide. Tranexamic acid (TXA) has been shown to be efficacious and safe in reducing mortality and morbidity if given within 3 hours of bleeding onset. Delayed PPH of more than 24 hours after delivery is a rare but high-risk ED presentation that requires timely management with TXA. This study aims to evaluate the patterns of TXA administration to treat delayed PPH in the ED using a retrospective review of medical reviews from 4 centres across a major urban Canadian city. Methods: We conducted a retrospective medical record review of patients presenting with PPH to 4 large urban EDs from 2013 to 2017; from 1.5 million ED visits, using a search for ICD-10 diagnostic codes of interest. Of these, the study cohort included only patients that were admitted to the hospital. Univariate analyses using Chi-squared tests and t-tests for non-continuous and continuous variables, respectively, were used to determine patient demographics and clinical characteristics significantly associated with TXA administration. Results: A total of 238 patients were included in the study cohort. Of these patients, 72.7% presented to the ED with mild hypovolemic shock, defined by a shock index score greater than 0.6. A total of 12.6% (95% CI 0.09-0.17) of patients were given TXA for PPH management in the ED. 67% (95% CI 0.47-0.82) of patients received the TXA within 3 hours of triage, whereas 33% (95% CI 0.18-0.53) received it after 3 hours, with the total mean time at 3.43 hours. 4.2% of patients required a blood transfusion and 2.9% required surgery. Univariate analyses indicated that greater maternal age (p = 0.028), lower hemoglobin levels (p = 0.014), higher shock index scores (p = 0.001), greater heart rate (p = < 0.001)), and use of oxytocin (p = <0.001) or blood products (p = < 0.001) in the ED were all significantly associated with TXA administration. Conclusion: The results from this study demonstrate that only 13% of delayed PPH patients presenting to the ED received TXA, and among those treated, 66% received TXA within 3 hours of presentation. The use of TXA was correlated with variables associated with an increased risk of morbidity. Given the rarity of delayed PPH presentation to the ED, the development of a treatment algorithm is recommended to ensure higher levels of timely TXA administration.

Triplet pregnancy of over 20 weeks gestation occurred 20 times during 75,506 deliveries at a referral hospital. Commonly occurring maternal complications included premature delivery (75%), antepartum anemia (35%), postpartum hemorrhage (35%), preeclampsia (20%), and premature spontaneous rupture of the membranes (20%). Malpresentation was common. Neonatal complications were also common and included respiratory distress syndrome (45%), presumptive sepsis (36.6%), hyperbilirubinemia (33%), and neonatal death (21.6%). These high complication rates emphasize the importance of early identification and referral center care for these vulnerable pregnancies.