Introduction: The aim of this study was: 1) To study the pattern of menstrual abnormality and severity in women on anticoagulant and antiplatelet drugs. 2) To analyze the correlation of prothrombin time (PT), International Normalised ratio (INR) and the bleeding severity. 3) To discuss the various management options in unexpected emergencies and menstrual complications in this subset of women on anticoagulants. Material & Methods: It is a prospective study, over a period of 18 months from July 2011 to december 2012. We had 44 women on antithrombotic therapy. 32 women were on anticoagulants and 12 were on antiplatelet agents. The severity of bleeding pattern was assessed with pictoral bleeding assessment chart (PBAC). 1) Out of 44 women studied, 32 women were on anticoagulants and 12 were on antiplatelet agents. 26 (81.25%) were on acenocoumarol, 5 (15.62%) on warfarin, 1 (3.12%) on heparin, among the 12 antiplatelet users, 8 (66.66%) were on aspirin and 4 (33.33%) on clopidogrel. 2) The indication for anticoagulants was mitral valve replacement (MVR) in 9, double valve replacement (DVR) in 6, aortic valve replacement (AVR) in 3, severe pulmonary artery hypertension (PAH) in 2, severe mitral stenosis (MS) with atrial thrombus in 2, deep vein thrombosis (DVT) in 5, severe mitral regurgitation (MR) in one, the other indications were subdural hematoma, thromboendarterectomy, chronic kidney disease (CKD) stage V, coarction of aorta, one each. The indication for antiplatelet therapy was percutaneous transluminal coronary angioplasty (PTCA) in 3, Wolf Parkinson White (WPW) syndrome + atrial fibrillation (AF), acute myocardial infarction (AMI), coronary artery bypass graft (CABG), mid basilar artery aneurysm, renal allograft recipient, dialated cardiomyopathy, aortic aneurysm repair, hypertension and unstable angina one each. Results: In women on anticoagulants (32), the main complaint was menorrhagia/heavy menstrual bleeding (HMB) in 20, polymenorrhoea with menorrhagia in 4, continuous per vaginal (PV) bleeding in 6. One lady had postmenopausal bleeding. Among the 12 antiplatelet users the main complaint was menorrhagia in 8, polymenorrhoea with menorrhagia in 2, postmenopausal bleeding in one. While on antithrombotic therapy apart from heavy menstrual bleeding, two women had intraperitoneal bleeding, two had post menopausal bleeding, two had secondary postpartum bleeding (PPH). CVA due to embolic stroke occurred in three, one during the study period. Subchoroidal haemorrhage causing choroidal detachment was noted in one. Conclusions: In patients with prolonged INR, excessive uterine bleeding can be an alerting initial manifestation. Antithrombotic therapy can cause HMB or exaggerate the symptom of HMB due to an underlying gynaec pathology. Mefanamic acid and norethisterone were used to arrest heavy menstrual bleeding. Antithrombotic therapy in women needs special consideration with alterations in menstrual pattern and contraception. Pregnancy and postpartum period present special challenges.
Chronic antithrombotic therapy involves the use of anticoagulants, antiplatelets given either as monotherapy or in combination for the prevention of thrombotic complications. The most feared and sometimes fatal complication with this the- rapy is bleeding. Anticoagulant therapy is mandatory in various diseases, such as in the postoperative period following cardiac valve replacement. The estimated incidence of venous thromboembolism (VTE) in women of reproductive age is 1 - 10 per 10,000 women per year. Deep vein thrombosis and pulmonary embolism are nearly always treated with oral anticoagulation (OA). Treatment can be either lifelong or limited for a period ranging from 6 weeks to a year, depending on the number and severity of thromboembolic events.
With the use of warfarin, the International Normalized Ratio (INR) that has been established to indicate adequately balanced therapy is between 2.0 and 3.0. The well-established benefits of anticoagulant therapy are significantly hampered by the possibility of major and sometimes fatal bleeding complications.
Bleeding can be classified as: a) major bleeding (that may include bleeds causing death or being life threatening, those requiring operation or medical intervention to stop bleeding, or causing permanent symptomatic organ damage or permanent changes in antithrombotic therapy). b) clinically relevant non major bleeds ( requiring cessation of antithrombotic therapy, and or change in therapeutic management), or c) minor (with minimal impact on clinical status of patients) [
Unfortunately, the need is not uncommon for antiplatelet (ASA + clopidogrel) and an anticoagulant combination in patients with heart valve prosthesis, AF, and acute coronary events or coronary stenting. In these pathological conditions, the theoretical advantage of thrombotic prevention should be considered against the risk of bleeding [
Hansen et al. [
Unique issues for women of reproductive age: 1) Menstrual problems can be exacerbated by anticoagulation [
Prevention of Hemorrhagic Ovarian Cysts: 1) Hormonal treatments may be used to suppress ovulation and formation of ovarian cysts. 2) Progestin-only methods which consistently suppress ovulation include the etonogestrel implant and DMPA. 3) The levonorgestrel IUD and progestin-only pills suppress ovulation for some, but not all, women, [
Why patients bleed? “The Golden Rule” in antithrombotic therapy: An abundance of literature supports what we have called “The Golden Rule” in antithrombotic therapy [
Aim: CARE hospital being a Cardiac, CT surgery and Vascular surgery centre, it is not uncommon to see women on anticoagulants and antiplatelet drugs. It is our endeavour to emphasize the work up and management of menstrual problems, challenges and complications in women on anticoagulant and antiplatelet drugs for various indications.
Women on anticoagulant and antiplatelet agents with menstrual problems, excessive and unscheduled bleeding per vaginum, advice regarding contraception and subfertility when referred to the gynaecologist the following protocol in history taking and assessment was followed.
History: How long have periods been heavy, is there flooding or passage of clots, how long do periods last and how often do they occur, has there been any change, is there any intermenstrual bleeding or post-coital bleeding, is there pelvic pain or dyspareunia, what contraception is being used and are cervical smears up to date (according to local screening programmes).
Assessment: Undertake pelvic examination and cervical smear (according to local screening programmes), haematology and biochemistry, imaging, endometrial sampling, hysteroscopy.
Assessing heavy bleeding in a clinical setting has its limitations. Hallberg and associates [
Pictorial bleeding assessment chart is a tool widely used in research settings to quantify menstrual blood loss. A pictorial chart score of 100 or more has been shown to have a specificity and sensitivity of 80% when used as a diagnostic test for HMB. F.Y. Huq et al. [
Other tools used to estimate menstrual blood loss include hemoglobin and hematocrit evaluation. Hemoglobin concentration < 12 g/dL increases the chance of identifying women with menorrhagia. A normal level, however, does not exclude menorrhagia, as many women with clinically significant bleeding have normal values.
Another method involves estimating of the number and type of pads used by a woman during menses. Warner and colleagues [
standardize this type of evaluation have lead to development of the pictorial blood assessment chart (
Scores are assigned as follows: 1 point for each lightly stained tampon, 5 if moderately saturated, and 10 if completely soaked. Pads are similarly given ascending scores of 1, 5, and 20, respectively. Small clots score 1 point, whereas large clots score 5. Totals more than 100 points per menstrual cycle have been shown to indicate >80-mL objective blood loss [
Limitations of the study: The number of cases is small, the study period is only for 18 months, the influence of patient-level variables on the association between anticoagulant intensity and risk of events has not been analysed.
1) Age
In this study out of the total 44 cases, 32 were on anticoagulants. The maximum cases were in the age group 21 - 30 yrs (40.6%). 28.12% were in the age group of 41 - 50, 21.8% in 31 - 40 yrs, 6.25% in 50 - 60 yrs. One case was 16 yrs and presented with menorrhagia. In this study out of the total 44 cases, 12 cases were on antiplatelet drugs. The maximum cases were in the age group 41 - 50 yrs (66.66%). 8.3% each in the age group of 21 - 30, 31 - 40 yrs, 50 - 60 yrs. One case was 78 yrs and presented with post menopausal spotting per vaginum (PV).
Menstrual Abnormality | ANTICOAGULANTS | Total | % (n = 32) | ||||
---|---|---|---|---|---|---|---|
ACITROM | WARFARIN | UFH | |||||
Menorrhagia | 18 | 2 | - | 20 | 62.5 | ||
Menorrhagia + Polymenorrhea | 4 | - | - | 4 | 12.5 | ||
Continuous PV Bleeding | 2 | 3 | 1 | 6 | 18.75 | ||
Post Menopausal Bleeding | 1 | - | - | 1 | 3.12 | ||
No Complaints | 1 | - | - | 1 | 3.12 | ||
Total | 26 | 5 | 1 | 32 | |||
Menstrual Abnormality | ANTIPLATELETS | Total | % (n = 12) | ||||
ASPIRIN | CLOPIDOGREL | ||||||
Menorrhagia | 6 | 2 | 8 | 66.66 | |||
Menorrhagia + Polymenorrhea | - | 2 | 2 | 16.3 | |||
Continuous PV Bleeding | - | - | - | - | |||
Post Menopausal Bleeding | 1 | - | 1 | 8.3 | |||
No Complaints | 1 | - | 1 | 8.3 | |||
Total | 8 | 4 | 12 | ||||
2) Menstrual abnormality
The most common menstrual problem among the anticoagulant (AC) users was menorrhagia, /heavy menstrual bleeding (HMB) seen in 62.5% (20/32), polymenorrhea with menorrhagia was seen in 12.5% (4/32). 18.75% (6/32) patients presented with continuous bleeding per vagina. One menopausal patient with postmenopausal bleeding accounting to 3.12%. One case (3.12%) had no menstrual complaints but presented with pain in abdomen. In this study, among the antiplatelet (AP) users the main complaint was menorrhagia seen in 66.66% (8/12), polymenorrhea with menorrhagia was seen in 16.3% (2/12). One menopausal patient with postmenopausal bleeding accounting to 8.3%. One case (8.3%) had no menstrual complaint
3) Contraception
Out of the 32 cases, 4 cases were in puerperal period and 2 were unmarried, all the 6 not requiring any contraceptive method. Eighteen out of 26 (69.23%) had undergone tubectomy, 15.38% (4/26) were using barrier method. 15.38% (4/26) were not using any method. Eleven out of 12 AP users (91.6%) had undergone tubectomy, 8.3% (1/12) one was not using any method.
4) Co-morbid conditions
In this study, among the anticoagulant users 6.25% (2/32) cases were noted having diabetes, 15.62% (5/32) were having pre existing hypertension. 9.37% (3/32) of the cases had co existing hypothyroidism and on adequate treatment. 15.62% cases had various other conditions.
In this study, 66.66% (8/12) of the antiplatelet users had hypertension, 25% (3/12) had diabetes. 41.66% (5/12) had hypothyroidism on adequate treatment. One case (1/12) had IgA nephropathy.
5) Drugs
Out of the total 44 cases, 32 were on anticoagulants and 12 on antiplatelet drugs. Majority of the cases, 26 were on acitrom and 5 on warfarin. Among the antiplatelet group, majority, 8 were on aspirin and 4 on clopidogrel (
6) Indication for anticoagulant and antiplatelet drugs
Of the 32 cases on anticoagulants the indication in 9 (28.12%) of them was mitral valve replacement (MVR), 6 (18.75%) had double valve replacement (DVR) and 3(9.37%) had aortic valve replacement (AVR). For 2(6.25%)cases it was severe pulmonary artery hypertension (PAH), severe mitral stenosis (MS) with atrial thrombus. 5/32(15.62%) cases it was due to DVT, the other indications were Subdural hematoma, thromboendarterectomy, chronic kidney disease (CKD) stage V, Coarction of aorta in 3.12% (1/32) each.
Of the 12 cases on antiplatelets drugs, the indication was PTCA in 25% (3/12).
Sl no | ANTICOAGULANT DRUGS | No. of cases | Total | %( n = 32) |
---|---|---|---|---|
1 | WARFARIN | 5 | 5 | 15.62 |
2 | ACITROM | 22 | 26 | 81.25 |
ACITROM + LMWH | 1 | |||
ACITROM + ASPIRIN | 3 | |||
3 | UNFRACTIONATED HEPARIN | 1 | 1 | 3.12 |
TOTAL | 32 | 32 | ||
ANTIPLATELET DRUGS | No. of cases | Total | % (n = 12) | |
1 | ASPIRIN | 8 | 8 | 66.66 |
2 | CLOPIDOGREL | 2 | 4 | 33.33 |
3 | CLOPIDOGREL + ASPIRIN | 2 | ||
TOTAL | 12 | 12 |
ANTICOAGULANTS | ||||||
---|---|---|---|---|---|---|
INDICATION | ACITROM | WARFARIN | UFH | Total | % (n = 32) | |
Severe PAH | 2 | - | - | 2 | 9.37 | |
DVR | 5 | 1 | - | 6 | 18.75 | |
MVR | 8 | 1 | - | 9 | 28.12 | |
AVR | 3 | - | - | 3 | 9.37 | |
Severe MS with atrial thrombus | 2 | - | - | 2 | 6.25 | |
Severe MR + commissural tear | 1 | - | - | 1 | 3.12 | |
DVT | 3 | 2 | - | 5 | 15.62 | |
Subdural hematoma | - | 1 | - | 1 | 3.12 | |
Thrombo end arterectomy | 1 | - | - | 1 | 3.12 | |
CKD stage V | - | - | 1 | 1 | 3.12 | |
Coarctation of aorta | 1 | - | - | 1 | 3.12 | |
Total | 26 | 5 | 1 | 32 | ||
ANTIPLATELET DRUGS | NO. OF CASES | Total | % (n = 12) | |||
INDICATION | ASPIRIN | CLOPIDOGREL | ||||
PTCA | 2 | 1 | 3 | 25 | ||
WPW syndrome + AF | 1 | - | 1 | 8.3 | ||
AMI | - | 1 | 1 | 8.3 | ||
CABG | 1 | - | 1 | 8.3 | ||
Mid basilar artery aneurysm | 1 | - | 1 | 8.3 | ||
Renal allograft recepient | 1 | - | 1 | 8.3 | ||
Dilated cardiomyopathy | 1 | - | 1 | 8.3 | ||
Aortic aneurysm repair | - | 1 | 1 | 8.3 | ||
Hypertension | 1 | - | 1 | 8.3 | ||
Unstable angina | - | 1 | 1 | 8.3 | ||
Total | 8 | 4 | 12 | |||
The indications were Wolf Parkinson White (WPW syndrome) + atrial fibrillation (AF), acute myocardial infarction (AMI), CABG, Mid basilar artery aneurysm, renal allograft recipient, dialated cardiomyopathy, aortic aneurysm repair, hypertension, unstable angina in 8.3% (1/12) each (
7) Complications
Catastrophic life threatening complications were noted in 7 cases (21.87%). CVA with embolic stroke accounted for 42.8% (3/7) of the complications with residual paralysis in 2 of the 3 cases. The thromboembolic episode had occurred before the patient was included in the study period. During the episode it was seen that INR was in the sub-therapeutic range.
One patient was noted to have Subchoroidal and vitreous haemorrhage with choroidal detachment. The event occurred before inclusion into the study pe-
riod. She was treated with laser pan photocoagulation.
Three of the 7 complications occurred during the study period. Two cases had major intraperitoneal bleeding. One was due to rupture of corpus luteal cyst of ovary, she was found to have severe anaemia. She was given 2 PRBC transfusions and anticoagulants were stopped for 3 days. IV antibiotic coverage was given.Evaluated with serial daily ultrasound for monitoring of regression of intraperitoneal haemorrhage (
One case, during the seventh month of pregnancy developed left lower limb deep vein thrombosis. She was started on LMWH 60 mg sc twice a day. IVC filter was placed. LMWH was stopped 12 hrs prior to induction. She had vaginal delivery. After 3 days oral anticoagulation with warfarin was started. Patient presented to the hospital ten days after discharge with heavy bleeding per vaginum. She was treated as a case of secondary PPH. Warfarin dose was readjusted.
8) BMI
In this study, among the anticoagulant users, 71.8% (23/32) were noted to have BMI in the range of 19 - 25, 21.28% (7/32) were in 26 - 30 and 6.25% (2/32) belonged to 31 - 40 range. Among the antiplatelet users 25% (3/12) were in the 19 - 25 range, 41.6% (5/12) were in the range of 26 - 30 and 33.33% (4/12) in the range of 31 - 40.
9) Hemoglobin levels
59.37% (19/32) of the cases had Hb > 10 gm%. 31.25% (10/32) cases had Hb between 8 - 10 gm%, 6.25 (2/32) between 6 - 8 gm%. One case (3.12%) had severe anaemia with Hb < 6 gm% in the anticoagulant users.
58.33% had Hb > 10 gm%, 25% (3/12) cases had Hb between 8 - 10 gm%, 8.3% (1/12) between 6 - 8 gm%.
One case (8.3%) had severe anaemia with Hb < 6 gm% in the antiplatelet users [
10) FSH level
Serum FSH levels were estimated in 31.8% cases (14/44). 8 of the cases were anticoagulant users and 6 were using antiplatelet drugs. 12.5% (4/32) and 33.33 (4/12) had levels < 15, 3.12% (1/32) and 16.6% (2/12) of them in between 15-25, 3 cases of the anticoagulant users who had levels of >25 were noted to have amenorrhea in the subsequent months of follow up (
Range of Hb (gm%) | No. of cases | Total | % (n = 32) | No. of cases | Total | % (n = 12) | |||
---|---|---|---|---|---|---|---|---|---|
ACITROM | WARFARIN | UFH | ASPIRIN | CLOPIDOGREL | |||||
>10 | 18 | 1 | - | 19 | 59.37 | 5 | 2 | 7 | 58.33 |
8 - 10 | 7 | 3 | - | 10 | 31.25 | 1 | 2 | 3 | 25 |
6 - 8 | 1 | 1 | - | 2 | 6.25 | 1 | - | 1 | 8.3 |
<6 | - | - | 1 | 1 | 3.12 | 1 | - | 1 | 8.3 |
Total | 26 | 5 | 1 | 32 | 8 | 4 | 12 |
FSH levels | No. of cases | Total | % (n = 32) | No. of cases | Total | % (n = 12) | |||
---|---|---|---|---|---|---|---|---|---|
ACITROM | WARFARIN | UFH | ASPIRIN | CLOPIDOGREL | |||||
<15 | 4 | - | - | 4 | 12.5 | 2 | 2 | 4 | 33.33 |
15 - 25 | - | 1 | - | 1 | 3.12 | 2 | - | 2 | 16.6 |
>25 | 2 | 1 | - | 3 | 9.37 | - | - | - | |
Total | 6 | 2 | - | 8 | 25 | 4 | 2 | 6 | 50 |
PBAC score | No. of cases | Total | % (n = 32) | No. of cases | Total | % (n = 12) | |||
---|---|---|---|---|---|---|---|---|---|
Acitrom | Warfarin | UFH | Aspirin | Clopidogrel | |||||
<100 | 1 | - | - | 1 | 3.12 | 2 | - | 2 | 16.6 |
100 - 200 | 23 | 5 | 1 | 29 | 90.6 | 5 | 4 | 9 | 75 |
>200 | 2 | - | - | 2 | 6.25 | 1 | - | 1 | 8.3 |
11) Organic lesion
In this study, evaluation to detect any co-existing organic lesion in pelvis was done. Among the anticoagulant users 25% (8/32) were detected to have fibroid, 9.3% (3/32) had ovarian cyst. 3.12% (1/32) had simple hyperplasia without atypia. In 62.5% (20/32) there was no pelvic pathology detected.
12) PBAC Score
PBAC score was calculated for all the cases per menstrual cycle. In the anticoagulant users 90.6% (29/32) the score was between 100 - 200. In 6.25% (2/32) it was >200. In one case who had no menstrual complaint the score was <100. In antiplatelet users 75% (9/12) the score was between 100 - 200, one case (8.3%) it was >200. In 16.6% the score was <100, out of which one case did not have any menstrual complaint and the other case presented with post menopausal bleeding per vaginum (
13) International Normalised Ratio (INR)
3/32 of AC users and 7/12 of AP users had INR <1, 13/32 and 3/12 cases had INR in the range of 1 - 2, 10/32 and 2/12 cases had INR in the range of 2 - 3. Out of 4 cases on anticoagulants who had INR in the range of 3 - 4, two of them had no organic lesion and two of them had uterine fibroids.
Two cases on anticoagulants had INR > 10 and PT > 120 (
Secondary PPH: One was a 29 yrs old, P2 L2 who developed DVT of left lower limb on the 3rd post operative day after LSCS. She was started on warfarin after adjusting the INR dose. 15 days later she presented with heavy bleeding per vaginum, INR was >10 and PT > 120 secs. She was admitted, anticoagulants stopped, 4 units of FFP and inj Vit K was given. Before discharge 2 more units of FFP was given and restarted on warfarin.
Postmenopausal bleeding: The other case was a 51 yr old postmenopausal lady with heavy bleeding and passage of clots since 3 days. On investigating her INR >10 and PT > 120 secs. Acitrom was stopped for 3 days, mefenamic acid
Sl no | INR | No. of cases | Total | % (n = 32) | No. of cases | Total | % (n = 12) | |||
---|---|---|---|---|---|---|---|---|---|---|
Acitrom | Warfarin | UFH | Aspirin | Clopidogrel | ||||||
1 | <1 | 2 | 1 | - | 3 | 9.37 | 5 | 2 | 7 | 58.33 |
2 | 1 - 2 | 12 | 1 | - | 13 | 40.62 | 2 | 1 | 3 | 25 |
3 | 2 - 3 | 9 | - | 1 | 10 | 31.25 | 1 | 1 | 2 | 16.6 |
4 | 3 - 4 | 2 | 2 | - | 4 | 12.5 | - | - | - | - |
5 | >10 | 1 | 1 | - | 2 | 6.25 | - | - | - | - |
Total | 26 | 5 | 1 | 32 | 8 | 4 | 12 |
Sl no | Treatment | No. of cases | Total | % (n = 32) | No. of cases | Total | % (n = 12) | |||
---|---|---|---|---|---|---|---|---|---|---|
Acitrom | Warfarin | UFH | Aspirin | Clopidogrel | ||||||
1. | Mefenamic acid | 16 | 5 | 1 | 22 | 68.75 | 3 | 3 | 6 | 50 |
2. | Norethisterone | 5 | - | - | 5 | 15.6 | - | - | - | - |
3. | Hysterectomy done | 3 | - | - | 3 | 9.37 | 2 | 1 | 3 | 25 |
4. | Advised hysterectomy | 1 | - | - | 1 | 3.12 | 1 | - | 1 | 8.3 |
5. | Advised hysteroscopy & endometrial curettage | - | - | - | - | - | 1 | - | 1 | 8.3 |
6. | No menstrual complaint | 1 | - | - | 1 | 3.12 | 1 | - | 1 | 8.3 |
was given for 3 days. Repeat INR after 3 days was 3.62. Uterine bleeding stopped after 3 days.
14) Management: Shown in
The most common indication for anticoagulants was cardiac valve replacement, accounting for 50% of the total 32 cases. These patients have to be on anticoagulants for life time. There is a constant risk of uterine bleeding throughout their lifetime.
PBAC scores were calculated per menstrual cycle. In this study 90.6% and 75% of anticoagulant and antiplatelet users respectively had a PBAC score between 100 - 200. The mean and median PBAC score in this study was 130 and 120 respectively. In the study conducted by Huq et al. [
Heavy menstrual bleeding:
In this study 62.5% and 66.66% cases of anticoagulant and antiplatelet users respectively presented with menorrhagia,(HMB). Even postmenopausal bleeding was seen in patients on anticoagulants and antiplatelet agents. Women of reproductive age experience heavy and prolonged menstrual bleeding whilst on OA therapy. Mean duration of menses increased from 5.6 to 6.1 days (P < 0.01), and reported menorrhagia from 44.2% to 70.8% (P < 0.001) [
Anticoagulants increase the risk of heavy menstrual bleeding (HMB). In menstruating women following VTE, rivaroxaban is associated with a two-fold higher risk of HMB compared with VKA. HMB predisposes to recurrent VTE episode, most likely due to the short interruptions of anticoagulation [
Anticoagulants, infertility and ART procedures:
One woman on anticoagulants who was planning conception had two cycles of ovulation induction and IUI. When counseling had to be done regarding ART procedures, the cardiologist’s opinion was sought. They were not in favour of ART procedures and gonadotrophin stimulation. In vitro fertilization may be considered where the risk of the procedure itself, including hormonal stimulation and pregnancy, is low. Thrombo-embolism may complicate in vitro fertilization when high oestradiol levels may precipitate a prothrombotic state [
Contraception in OA users: In this study, 56.25% of anticoagulant and 91.6% of antiplatelet users had undergone tubectomy as a method of permanent sterilization. Two were planning conception and four cases were in puerperium, did not need any form of contraception. In this study there was no case who was using OCP or IUCD. Contraceptive choices include barrier methods, sterilization and progestin-only contraception orally, injection, implant and intrauterine system. In the study conducted by Huq et al. [
As per the WHO Medical Eligibility Criteria (MEC) 2015 [
Ida Martinelli [
Women suffer more bleeding complications than men when receiving new oral anticoagulants for VTE [
Fibromyoma and DVT:
In the study conducted by Huq et al [
Intra peritoneal bleeding:
Two cases of intraperitoneal bleeding were successfully managed with conservative measures in our series. So an unnecessary laparotomy could be avoided by keeping the patient under observation. Gupta A. et al [
INR and bleeding complications:
As per accepted norms the dose of the anticoagulants were adjusted in the therapeutic range so that the INR is maintained between 2 - 3. In this study 40.62% had INR in the range of 1 - 2 and 31.25% had INR in the range of 2 - 3. Two cases were seen with INR > 10. Excessive uterine bleeding is a revealed form of bleeding which should alert the treating physician to monitor INR. In such cases remedial measures can be instituted early before any other fatal bleeding occurs. The inception cohort, observational ISCOAT study [
In this study 68.73% of anticoagulant users and 50% of antiplatelet users showed improvement with NSAID-mefenamic acid. Norethisterone was the drug that was most effective to arrest menstrual bleeding in the cases that were seen in the immediate post operative period of cardiac surgery. Tranexamic acid is not recommended in these cases because of the theoretical possibility of increased risk of thrombosis. The efficacy and safety of the use of tranexamic acid in patients at higher risk for thromboembolism (such as those requiring anticoagulation) have not been established, but in general, these patients should not receive tranexamic acid [
Hysterectomy:
In our study, DVT was the indication for anticoagulant use in 5/32. Fibromyoma was the cause of DVT in two of the cases [
Oral anticoagulant therapy is increasingly used for the prevention and treatment of thromboembolic complications of cardiovascular disease. Bleeding is the most important complication of anticoagulant therapy and ranges from fatal, major to minor bleeding episodes. The use of INR increases the reliability of anticoagulant control. Monitoring with INR helps in avoiding unnecessarily high doses, associated with higher bleeding rates and optimum therapeutic ranges can be more easily achieved. Usually, intensity of anticoagulation achieved is related to bleeding. When bleeding events occur at very low INR it implies that many bleeds during oral anticoagulation are not related to the intensity of anticoagulation but to a local bleeding source that may be unmasked by anticoagulant therapy.
Women of reproductive age experience increased menstrual loss and change in menstrual pattern while on OA therapy. It is therefore recommended that all women of reproductive age on OA therapy should be provided with proper counselling about the possible changes in their menstrual pattern and increased menstrual bleeding. They should be monitored for HMB and other menstrual problems to ensure that appropriate treatment is instituted without delay and their quality of life improved. An unplanned pregnancy would lead to an increased risk of venous thromboembolism, and any further thromboembolic event presents a management dilemma in these patients who are already fully anticoagulated. They would also be at increased risk of intraoperative bleeding complications if they underwent a termination of pregnancy. These challenges highlight the importance of proper counselling about available contraceptive choices and the dangers that an unplanned pregnancy would present to these women.
We thank the team of cardiologists and cardiovascular surgeons at CARE hospitals, Hyderabad, for their cooperation to conduct this study.
The authors declare that they have no conflict of interest.
Devabhaktuni, P., Thomas, P., Kapadia, A., Sridevi and Bhupatiraju, S. (2017) Menstrual Abnormalities and Gynaecological Problems in Women on Anticoagulant and Antiplatelet Therapy: Management Options. Open Journal of Obs- tetrics and Gynecology, 7, 581-599. https://doi.org/10.4236/ojog.2017.75061