Endogenous Heparin-Like Substances May Cause Coagulopathy in a Patient with Severe Postpartum Hemorrhage

Abstract

Introduction: Postpartum hemorrhage (PPH) is associated with maternal morbidity and mortality. Accurate diagnosis of the cause of puerperal hemorrhage is as important as treatment strategies for resuscitation. We report a case of coagulation disorder caused by endogenous heparin-like substances in a PPH patient. Case Presentation: A 30-yearold woman with no medical history of bleeding disorders suffered intractable hemorrhage following spontaneous delivery in a local hospital. The patient was transferred to the department of obstetrics of a superior hospital. On arrival, the patient was found to have severe hemorrhagic anemia, hemorrhagic shock, and disseminated intravascular coagulation. Active treatments were performed, but the patient continued bleeding. Laboratory testing, performed during early treatment, revealed that all coagulation factors were below normal. The differences between CK-TEG R-time (reaction time in citrated kaolin thromboelastography assay) and CKH-TEG R-time (reaction time in citrated kaolin with heparinase thromboelastography assay) suggested the presence of heparin activity. However, the patient's family denied heparin use prior to presentation. Thus, we deduced that endogenous heparin-like substances were the main cause of the coagulopathy. After receiving treatment with protamine, the patient stopped bleeding. Meanwhile, all coagulation parameters and the TEG assay results improved. Conclusions: In this case report, TEG assay suggested the presence of heparin activity in a PPH patient, and treatment also highlighted the importance of analyzing different parameters in TEG.

Case report: New clinical clue of hyper-endogenous heparinization provides an imperative guideline for Treatment of Postpartum Hemorrhage with DIC via TEG guides and protamine intervention

“…Normally, endogenous heparinization is rare in PPH patients. Recently, the endogenous heparinization of PPH patient with DIC was reported by Wang et al, (2019). Herein both cases (including our case) have demonstrated the importance of recognition of high heparinization in PPH.…”

“…Moreover, the diagnosis of this patient was associated with intrauterine infection before surgery (2018-11-15 21:32, Table 1). When compared with Wang et al, (2019) report without infection, our report shows that the occurrence of endogenous heparinization in pregnant women is obviously accompanied by the infection. In this process has been accompanied by a severe infection in patients with the phenomenon, the 2018-11-15 is also found in the blood culture of E. coli infection, caused by infection with in ammation and ischemia reperfusion of great damage to vascular endothelial cells, and re ect the index of TM in patients with vascular endothelial injury and tPAI-C levels are shown as standard of heparinization aggravating gradually rising phenomenon.…”

“…Herein both cases (including our case) have demonstrated the importance of recognition of high heparinization in PPH. Nevertheless, the effect of heparin in that case was identi ed within 24 hours and the syndrome was relieved at 72 hours (Wang et al, 2019). Notably, this phenomenon of endogenous heparinization needs to get an insight into concerning the interference of catheter heparin sealing which heparin leaks into the vein to cause the obscure outcome such as endogenous plus exogenous heparin or exogenous heparin alone problem.…”

Severe Hemorrhage Secondary To IgA Vasculitis With Varicella Infection: A Case Report

“…Patients may have ecchymosis, mucosal hemorrhage, hematuria, gastrointestinal bleeding, and bleeding at the injection site and wound. Heparin-like substances lead to prolongation of APTT, PT, TT, and cannot be corrected by ordinary plasma infusion in such patients 22 . The above studies are consistent with the clinical manifestations of child we reported, supporting the speculation that IgA vasculitis complicated by chickenpox may induce heparin-like substances.…”

Structural, molecular biology and the immunopathology of SARS-CoV-2: An updated review

“…upper respiratory tract, salivary gland) may influence viral entry through cleavage of S2' site during fusion mediated viral entry (71,83,84). However, one cannot rule out the possibility of cross-talk between heparan sulphate proteoglycans in the host cell surface, and furin-like cleavage sites in SARS-CoV-2 (84,85), as high level of heparan sulphate proteoglycans may cause coagulopathy during COVID-19 (86). More studies on furin-like cleavage sites are urgently needed.…”