Comparative effectiveness of oxytocin, carbetocin, and tranexamic acid for postpartum hemorrhage prevention in cesarean deliveries: a prospective cohort analysis.

OBJECTIVES

To evaluate the comparative effectiveness of four pharmacologic regimens - oxytocin, carbetocin, oxytocin plus tranexamic acid (TXA), and carbetocin plus TXA - for postpartum hemorrhage (PPH) prophylaxis in cesarean deliveries.

METHODS

This prospective cohort study was conducted at a tertiary center in Istanbul, Turkey, between March 2024 and January 2025. A total of 400 women undergoing cesarean delivery at 34+0-39+6 weeks of gestation were sequentially assigned to one of four prophylactic intervention groups (n=100 each): oxytocin, oxytocin+TXA, carbetocin, or carbetocin+TXA. Medications were administered post-placental delivery. Third-stage labor management was standardized. Primary outcomes included estimated blood loss (EBL), 24-h hemoglobin change (ΔHb), and need for transfusion or intravenous iron. Baseline neonatal characteristics, including birthweight and Apgar scores, were recorded to ensure comparability across groups.

RESULTS

Baseline characteristics were similar across groups. Hemoglobin decline differed significantly (p=0.015), being lowest in the carbetocin+TXA group (7.73 ± 6.68 %) and highest in the oxytocin group (10.70 ± 7.23 %). Although mean EBL was lowest in the carbetocin+TXA group, the difference was not statistically significant (p=0.172). Transfusion and iron supplementation rates were low and comparable. No adverse neonatal outcomes were observed.

CONCLUSIONS

Carbetocin combined with TXA was associated with the most favorable hematologic profile. These findings support the use of multimodal pharmacologic strategies for PPH prevention in cesarean births and may inform future protocol development.