///2013 Abstract Details
2013 Abstract Details2019-08-02T16:57:45-05:00

Protamine use in a parturient with massive hemorrhage from placental abruption while receiving intravenous heparin

Abstract Number: S 55
Abstract Type: Case Report/Case Series

Yelena Spitzer MD1 ; Jeffrey Zahn M.D.2; Yaakov Beilin M.D.3

Introduction: Antepartum thromboembolic disease occurs in approximately 0.1% of pregnancies and is commonly treated with intravenous heparin administration. Therapeutic heparinization can contribute to uncontrolled hemorrhage. We describe a case of a woman who was fully anticoagulated from heparin and started to hemorrhage from a placental abruption.

Case report: A 32 year old gravid 1 para 0 woman, at 28 weeks gestation was admitted to the labor and delivery suite with left lower extremity swelling and diagnosed with a left deep venous thrombosis (DVT). She was started on a continuous infusion of heparin in an effort to reach a therapeutic level of aPTT > 2x normal. The patient also had a history of chronic hypertension and had extensive fibroid disease despite prior myomectomy in 2004. The planned mode of delivery was a cesarean delivery with hysterectomy at term. On hospital day 3, with the aPTT at > 1.5 x normal, the patient developed extensive vaginal bleeding. Heparin was immediately stopped and the patient was taken to the operating room (OR). After placement of two large bore IV’s and an arterial line, rapid sequence induction of anesthesia was achieved with etomidate 12mg and succinylcholine 100mg. Protamine sulfate 20mg was started and a massive transfusion protocol (MTP) was initiated. Prior to arrival to the OR, estimated blood loss (EBL) was 2000 mL. A vertical incision was made and the baby was delivered with Apgar scores of 9 and 9 at 1 and 5 minutes. Resuscitation was ongoing and totaled 3 liters of crystalloid, most given prior to entry into the OR, 10 units packed red blood, 8 units FFP, 2 units pooled platelets and 1 unit cryoprecipitate. Total EBL was 4 liters. The patient remained hemodynamically stable and was transferred tracheally intubated to the medical intensive care unit (MICU). Her trachea was extubated approximately 6 hours after arrival to the MICU and she was discharged to home on postoperative day 7. She did not require any blood products postoperatively.

Discussion: Pregnancy is a known hypercoagulable state with an approximate 0.05% incidence of DVT. There are few reports in the literature regarding protamine use in pregnant women. To our knowledge, this is the first case reported of protamine use to reverse intravenous heparin in a pregnant woman for emergent cesarean section for massive hemorrhage. Protamine is a highly cationic peptide. It binds to heparin to form a stable ion pair which has no anticoagulant activity. The heparin-protamine complex is then broken down by the reticuloendothelial system. Our patient was also at risk for placental abruption due to her preexisting hypertension. The combination of abruption in the fully anticoagulated patient was a challenge. The use of protamine along with MTP and immediate delivery all contributed to the successful outcome.

SOAP 2013