Is tranexamic acid (TXA) contraindicated as prophylaxis in a patient with a history of cerebral vascular accident (CVA) ischemic stroke undergoing hysterectomy with retained products due to high risk of post-operative bleeding?

Use of Tranexamic Acid in a Patient with Previous CVA Ischemic Stroke Undergoing Hysterectomy

Tranexamic acid (TXA) can be safely administered as prophylaxis prior to hysterectomy in a patient with previous CVA ischemic stroke during pregnancy who is at high risk for post-operative bleeding. Recent high-quality evidence supports the safety of TXA in surgical settings without increased risk of thromboembolic complications 1.

Safety Profile of TXA in Patients with Previous Stroke

• A meta-analysis of 216 trials (125,550 participants) across various clinical settings found no evidence of increased risk of thromboembolic complications with TXA use 1
• Another meta-analysis focusing specifically on non-cardiac surgery (191 RCTs, 40,621 participants) also found no evidence of increased cardiovascular thromboembolic complications, seizures, or mortality at 30 days 1
• While there are theoretical concerns about thrombotic risk in patients with previous stroke, the evidence does not support withholding TXA in these patients when there is a clear indication for bleeding risk reduction

Dosing and Administration

For hysterectomy with retained products where bleeding risk is high:

• Administer 1g of TXA intravenously prior to surgery 1
• Consider a second dose if bleeding persists or recurs within 24 hours 1
• Timing is crucial - TXA should be given as early as possible, ideally within 3 hours of the start of surgery 1

Benefits in Gynecological Surgery

• TXA has been shown to effectively reduce bleeding complications in hysterectomy:
  • Reduced intraoperative blood loss 2
  • Decreased incidence of blood loss ≥500 mL 2
  • Reduced need for reoperations due to postoperative hemorrhage 2
  • Number needed to treat of 24 to prevent one reoperation for bleeding 2

Contraindications and Cautions

TXA is contraindicated in:

• Disseminated intravascular coagulation (DIC) 1
• Active thromboembolic disease

Use with caution in:

• Patients with massive hematuria (risk of ureteric obstruction) 1
• Patients on oral contraceptive pills (increased thrombotic risk) 1

Monitoring and Additional Considerations

• Monitor for clinical signs of thrombosis during and after surgery
• Avoid very high doses (>2g/day) as there may be a dose-dependent increase in seizure risk 3
• Consider combining TXA with other hemostatic measures if bleeding risk is extremely high:
  • DDAVP may be added as a second-line agent if needed 1
  • For persistent bleeding, platelets or fresh frozen plasma may be considered 1

Algorithm for Decision-Making

1. Assess baseline bleeding risk (high in this case due to retained products)
2. Confirm absence of absolute contraindications (DIC, active thrombosis)
3. Administer 1g TXA IV immediately before surgery
4. Monitor for bleeding during procedure
5. If significant bleeding occurs or is anticipated post-operatively:
   • Consider second dose of TXA (within 24 hours)
   • Add DDAVP if additional hemostatic support needed
   • Reserve blood products for significant ongoing bleeding

In conclusion, the benefits of TXA in reducing bleeding complications during hysterectomy outweigh the theoretical risks in a patient with previous ischemic stroke, particularly when the risk of post-operative bleeding is high. The most recent and high-quality evidence supports its use in this clinical scenario.