Reteplase/tranexamic acid
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Bleeding and pulmonary embolism: case report A 30-year-old woman developed cardiac arrest caused by a massive pulmonary embolism during treatment with tranexamic acid for heavy menstrual bleeding. She also developed heavy internal bleeding while receiving thrombolysis with reteplase [routes and durations of treatment to reactions onset not stated]. The woman called emergency services because she was feeling unwell and having difficulty breathing. She experienced cardiac arrest with pulseless electrical activity while being being transported to the ambulance. CPR was initiated, and she was intubated in the emergency room. She received atropine, epinephrine [adrenaline] and bicarbonate, and spontaneous circulation was restored after 15 minutes. Transthoracic echocardiography revealed a dilated right ventricle, a pressure gradient of 43mm Hg across the tricuspid valve and fluttering elements in the right heart chamber. A diagnosis of massive pulmonary embolism was made. A short time later, she once again went into a state of pulseless electrical activity. Thrombolysis with reteplase 10IU was started, and spontaneous circulation was restored after 75 minutes. Due to abdominal distention and a haemoglobin level of 4.4mM, heavy internal bleeding was suspected. CT scans of the thorax and abdomen revealed bilateral pulmonary embolisms, haemomediastinum, a large subphrenic accumulation of fluid on the right side, a possible liver rupture and a reduced quantity of free fluid in the pelvis minor. She received blood, fresh frozen plasma, thrombocyte concentrate and sodium chloride. She continued to experience bleeding, with worsening lactic acidosis, and died later that night. According to the woman’s hospital records, she had started treatment with tranexamic acid 1g three times daily and medroxyprogesterone [Perlutex] 6 months previously due to heavy menstrual bleeding. The bleeding had stopped after 3 weeks. Tranexamic acid should have been stopped at this point, but it was unclear whether or not she had continued to receive the drug. The hospital electronic medication system showed the prescription was still active at the time of her latest admission. Author comment: Fibrinolysis inhibitors are frequency used to treat heavy menstrual bleeding. They are considered safe, even though thromboembolism is cited as a side effect. . . In the case of our patient, it is clear that the combination of cardiac massage and thrombolysis contributed to her hypocoagulable state and the heavy internal bleeding which ensued. Gybel M, et al. Cardiac arrest caused by massive pulmonary embolism during treatment with tranexamic acid. Ugeskrift for Laeger 175: 1426-1427, No. 20, 13 803095399 May 2013 [Danish; summarised from a translation] - Denmark
0114-9954/13/1477-0001/$14.95 Adis © 2013 Springer International Publishing AG. All rights reserved
Reactions 9 Nov 2013 No. 1477
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