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Patient with placental abruption resulting in severe postpartum hemorrhage develops acute kidney failure following treatment with tranexamic acid
Abstract Number: S1D-4
Abstract Type: Case Report/Case Series
We present a case of placental abruption (PA) resulting in IUFD and life threatening DIC, treated with tranexamic acid (TA) in a patient (pt) who went on to develop acute renal failure (ARF) requiring hemodialysis (HD). A 23-year-old G5P1031 at 31 wks presented with painful vaginal bleeding (VB), stable vitals and no FHR. The OB team proceeded with induction of labor (IOL) for PA with IUFD. Initial labs were Hg 10.3g/dL, plts 181thou/mcL, Cr 1.0mg/dL and fibr 63mg/dL, INR 1.3 and PTT 38s. 2 units (u) FFP were transfused to treat low fibrinogen. The patient also had elevated blood pressures, raising concern for pre-eclampsia.
The pt developed worsening VB and repeat labs deteriorated (Hg 6.8 g/dL, plts 45 thou/mcL, fibr <50 mg/dL, PT 16.7, INR 1.6, and a PTT of 39 s). After multidisciplinary discussion with anesthesia, a decision was made to treat DIC with massive transfusion and TA prior to surgical management. 3u PRBCs, 2u pooled platelets, 2u FFP and 2u cryoprecipitate were rapidly given and TA 1g in 100 ml of NS was administered over 20 minutes. Following treatment (tx), VB slowed, significant cervical dilation was noted and followed shortly by a SVD. Postpartum, thrombocytopenia and renal dysfunction persisted (Cr 1.9-5.9 mg/dL and plts 39-45 thou/mcL). Hematology was consulted confirming a diagnosis of microangiopathic hemolytic anemia, thrombocytopenia and ARF. A thrombomodulin gene mutation was identified on genetic studies, suggesting atypical hemolytic uremic syndrome (aHUS), a diagnosis which can be associated with pregnancy. Eculizumab, an anti-C5 complement therapy for tx of aHUS was started. The pts plts began improving, but she continues to require HD months after delivery.
TA is an antifibrinolytic used to treat PPH. The recent WOMAN trial indicated 1g of IV TA given within 3 hrs of birth significantly reduced death due to bleeding in PPH pts. In addition, this trial and others have not found any increased thromboembolic complications in the TA group. However, there are concerns about external validity of the WOMAN trial due to the highly selective population involved. Making assumptions for safe usage of TA in certain sub-populations like those with renal failure, DIC and history of thromboembolic disease is potentially dangerous. Reports of acute renal cortical necrosis associated with TA exist. Product information states pts with renal impairment should be observed for toxicity such as thromboembolism and seizures, as TA is primarily eliminated in urine. TA has been used in pts with PA and DIC with success at reducing bleeding, but this case highlights the complex nature of using TA in pts with renal impairment and potential thromboembolic risk. The implications of using TA in a pt with aHUS is unknown and cannot be determined from this single report. However, this case describes chronic and severe morbidity associated with TA use in a critically ill pt.
Ref: WOMAN Trial Collaborators. WOMAN Trial. Lancet. 2017;389:2105–2116