A Short Course of Tranexamic Acid to Continue Anticoagulation and Control Bleed in Cerebral Venous Thrombosis with Abnormal Uterine Bleeding and Anemia.

A 45-year-old lady presented with headache and vomiting. Her CT brain with contrast showed left transverse sinus thrombosis. She had AUB for 6 months and was on HPs. On day 3 of anticoagulation, she had vaginal bleeding. Oral TXA was given at the dose of 500 mg thrice a day for 5 days. Her vaginal bleeding stopped and anticoagulation was continued. She was discharged on oral anticoagulation with mRS 0. All patients were started on unfractionated heparin 5000 i.u. subcutaneous, 6 th hourly at admission, and overlapped with Acecnocoumarol (4 mg on day 1 , 3 mg on day 2 , 2 mg on day 3 , and continued based on INR). Target INR was 1.5–2.5. Patients were discharged on acenocoumarol at discharge and had mRS 0 at discharge and after 3 months. None of them had a recurrence of severe vaginal bleeding subsequently and two patients were advised surgical excision of fibroid, and two were on progestin preparations, which were daily oral pills in one patient and monthly depot preparations in the other. The TXA was stopped after the complete cessation of bleeding. No adverse effects were observed. It was thus reliably concluded that a short course of TXA at a relatively lower dose is effective at controlling breakthrough vaginal bleeding without causing any major adverse effects. A normal menstrual cycle has a frequency of 24 to 38 days, and lasts 7 to 9 days with 5 to 80 mL of blood loss. Variations in any of these parameters constitute abnormal uterine bleeding. The FIGO divides the causes of AUB into structural (polyp, adenomyosis, leiomyoma, malignancy, and hyperplasia), nonstructural (ovulatory dysfunction, coagulopathy, endometrial disorders, and iatrogenic), and not otherwise classified.[ 3 ] Therapeutic options to manage thrombotic episodes with AUB include intrauterine hormonal implant, endometrial ablation, hysteroscopic resection of fibroids, embolization, and tranexamic acid.[ 6 ] Tranexamic acid is a trans-stereoisomer of 4-(aminomethyl) cyclohexane-carboxylic acid, which prevents plasmin activation, reduces fibrinolysis, and stabilizes clots, without enhancing new clot formation. The TXA 1 g three times daily for 5 days significantly reduced tissue plasminogen activator and plasmin activity in the menstrual and peripheral blood of menorrhagic women, compared with pretreatment values.[ 7 8 ] Although active thromboembolism is a relative contraindication, other treatment options were limited in our cases, so TXA was used after discussion with the gynecologist, and close neurological monitoring was done to look for worsening. There are only single case reports of AUB with CVT in which the coexisting AUB was managed with hormonal intrauterine devices,[ 9 ] and a short course of TXA. Out of all the options available to control emergent vaginal bleeding, TXA was the safest as hormonal preparations were contraindicated. However, since some studies conclude on the evidence of TXA being thrombogenic in a few case reports,[ 9 ] it was used at a small dose and only for a few days during breakthrough bleeding alone in our case series so as not to increase the risk of thrombosis. We did not find any neurological worsening with the dose and duration of TXA used. Our study is one of its own that has seen a cohort of four patients as compared with previous isolated case reports, who responded to the uniform treatment protocol of TXA with anticoagulation. The limitations of our study were a small number, nonexclusion of prothrombotic disorders, and only a short course of TXA. In conclusion, this case series attempts to highlight the importance of AUB and the intake of HPs as a common cause of CVT in young women, which might create challenges in treatment. The low-dose TXA is effective in mitigating breakthrough vaginal bleeding while the patient is on anticoagulants. This observation needs larger prospective studies to further confirm.

Nil.

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There are no conflicts of interest.