2016 FSA Posters

P036: AORTOILIAC THROMBOSIS FORMATION FOLLOWING TRANEXAMIC ACID ADMINISTRATION IN HIGH-RISK PARTURIENT PATIENT
Omar Hajmurad, MD, Shayan Bengali, Ankeet A Choxi, MD, Zahira Zahid, MD, Roman Dudaryk, MD; University of Miami/Jackson Memorial Hospital

Introduction: Abnormal placentation and peri-partum hysterectomy are known risk factors for obstetric hemorrhage – remaining a leading cause of preventable mortality.  Tranexamic acid (TXA) has been shown to reduce blood loss in various surgical settings. TXA appears to be a promising drug for the prevention and treatment of peripartum hemorrhage (PPH) after both vaginal and caesarean delivery. Despite a well-established safety profile, the possibility of thrombotic complications remains to be a concern.  We describe the use of prophylactic TXA during an urgent cesarean delivery-total hysterectomy in a patient with placenta percreta for whom bilateral aorto-iliac thrombosis were diagnosed postoperatively.

Case Discussion: 35 year-old multiparous woman presented at 30 weeks with vaginal bleeding.  Previously, patient was diagnosed with placenta previa concerning for placenta percreta with uterine myoma. A multidisciplinary meeting concluded that a cesarean delivery-total hysterectomy with placement of hypogastric artery balloons at 34 weeks would be the best treatment plan.

At 32 weeks, patient suffered another episode of bleeding – leading to urgent cesarean delivery-total hysterectomy.  Preparations to contain massive hemorrhage were made by notifying blood bank for possible MTP, having 10 units FFP and PRBCs in OR, and alerting Trauma and Vascular surgical teams to be on standby. Prior to induction, IR performed pelvic arteriogram and placed bilateral hypogastric artery fogarty balloons. Following induction, arterial line and central and peripheral access were obtained. A loading dose of 1g TXA was given, followed by an infusion over 8 hours.  Following uneventful cesarean, temporary balloon occlusion of bilateral hypogastric arteries occurred approximately 15 minutes into the hysterectomy to prevent bleeding.  Surgery was uncomplicated with minimal bleeding and no required transfusions.  Post-operatively, TXA was discontinued and arterial balloons were removed.  

Postoperatively, evaluation found non-palpable bilateral PT and DP pulses.  Lower extremity ultrasounds were negative for occlusion.  Temporary vasospasm was suspected. Examination by IR and Vascular Surgery on POD#1 revealed similar results. Upon further questioning, the patient reported a history suggestive of Raynaud’s symptoms, for both herself and her twin.  CT angiogram showed patent hypogastric arteries, but bilateral external iliac artery thrombus with common femoral extension as well as renal vein thrombus.  Anticoagulation was started.  On POD#3, the patient underwent angiogram with bilateral aorto-iliac embolectomy uneventfully.  On POD#6, patient was discharged home on a 6-month course of anticoagulation.

Discussion: TXA may be a useful adjunct in the prevention and treatment of PPH, particularly for patients with multiple risk factors for post-partum/post-surgical hemorrhage. However, consideration should be given towards prothrombic risks; including hypercoagulable state of pregnancy, pre-existing vaso-occlusive disease, procedures involving vascular instrumentation; as well as the post-surgical inflammatory state and predisposition to venous stasis.  In the presence of these risk factors, it may be prudent to reserve the administration of TXA for therapeutic, rather than prophylactic treatment of hemorrhage in parturients.