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Temporal Correlation of Tranexamic Acid Administration and Eclamptic Seizure in a Patient with Renal Insufficiency
Abstract Number: S1D-3
Abstract Type: Case Report/Case Series
Introduction: Administration of tranexamic acid (TXA) to patients with postpartum hemorrhage (PPH) reduces maternal mortality due to hemorrhage (1). The cardiac anesthesia literature suggests moderate to high dose TXA (25-100 mg/kg), which is renally-cleared, increases risk of seizure (2,3). It is unknown whether TXA administration to pre-eclamptic patients with renal insufficiency affects the incidence or severity of eclamptic seizure.
Case: A 33 year-old, 71 kg, gravida 1, para 0 at 41 wks gestation with no significant past medical history underwent a primary low-transverse cesarean delivery for active phase arrest under neuraxial anesthesia. She had no seizure history and no signs or symptoms of pre-eclampsia prior to surgery. She received 30 mL 2% lidocaine, 15 mL 3% chloroprocaine, and 100 mcg fentanyl via epidural, and 4 mg midazolam IV. The procedure was complicated by uterine atony for which she received oxytocin 30 U IV, methylergonovine 200 mcg IM x 2, misoprostol 1 mg PR, carboprost 250 mcg IM, a B-Lynch suture, and TXA 1 g IV; estimated blood loss was 1600 mL and urine output was 600 mL. Other intraoperative medications included sodium citrate, cefazolin, azithromycin, ondansetron, phenylephrine, and fibrinogen concentrate. She developed sporadic mild-range blood pressures throughout the case. Intraoperative laboratory analysis was significant for sodium 134 mmol/L, blood urea nitrogen 22 mmol/L, and creatinine 2.41 mg/dL, which prompted diagnosis of pre-eclampsia with severe features. In the recovery room, approximately 130 minutes after the TXA dose, the patient developed altered mental status and a 3-minute generalized tonic-clonic (GTC) seizure. She was treated with airway support and a 6 g magnesium sulfate IV bolus. Towards the end of the bolus, she exhibited another GTC seizure for which she was administered 4 mg midazolam IV and the remainder of the bolus, followed by an infusion of 2 g/hour. A non-contrast head computed tomography scan was negative for cerebral edema, hemorrhage, and posterior reversible encephalopathy syndrome. She did not exhibit further seizure activity and her creatinine normalized after 48 hours. The remainder of her recovery was significant only for a self-resolving small bowel obstruction.
Discussion: The WOMAN Trial demonstrated no difference in seizure incidence among PPH patients who received TXA versus placebo, however pre-eclamptic patients were not specifically analyzed (1). This case demonstrated rapid progression from development of mild- range blood pressures to eclampsia with recurrent seizure activity despite magnesium therapy in the setting of recent TXA administration. While there is no way to determine if TXA contributed to the incidence or severity of seizure activity, it may be reasonable to withhold or reduce the dose of TXA in the setting of pre-eclampsia with renal insufficiency.
1. WOMAN Trial. Lancet. 2017.
2. Myles et al. NEJM. 2017.
3. Koster et al. BJA. 2013.