How to manage hemoperitoneum in a patient with rheumatic heart disease (RHD) status post mitral valve replacement (MVR) with a deranged International Normalized Ratio (INR) on warfarin (Coumadin)?

Management of Hemoperitoneum in RHD Post-MVR with Deranged INR on Warfarin

Immediately administer prothrombin complex concentrate (PCC) 25-50 U/kg IV plus intravenous vitamin K 10 mg by slow infusion, along with packed red blood cells to reverse the coagulopathy and treat hemorrhagic shock—the risk of death from continued bleeding far exceeds the risk of valve thrombosis in this life-threatening scenario. 1, 2

Immediate Resuscitation (First 15 Minutes)

Reversal of Coagulopathy

• Administer 4-factor PCC immediately at weight-based dosing: 25 U/kg if INR 2-4,35 U/kg if INR 4-6, or 50 U/kg if INR >6, targeting INR <1.5 1, 2
• PCC achieves INR correction within 5-15 minutes versus hours with fresh frozen plasma, making it the preferred agent for life-threatening bleeding 2
• Add IV vitamin K 10 mg by slow infusion over 30 minutes concurrently with PCC—despite the mechanical mitral valve, the immediate bleeding risk outweighs the delayed thrombosis risk 1, 2
• Vitamin K takes 12-24 hours to work but provides sustained reversal, preventing rebound coagulopathy 2

Hemorrhagic Shock Management

• Transfuse packed RBCs immediately to target hemoglobin >7-8 g/dL and maintain hemodynamic stability 1
• Avoid crystalloids alone (normal saline, Ringer's lactate) as primary resuscitation—they worsen dilutional coagulopathy and fail to restore oxygen-carrying capacity 1

Critical Care Management (First 24 Hours)

Additional Coagulation Support

• Administer fresh frozen plasma (FFP) 15-30 mL/kg if coagulopathy persists after PCC, with at least 30 mL/kg required for established coagulopathy with PT/aPTT >1.5 times normal 1
• Inadequate FFP dosing (1-2 units) is insufficient—this is a common pitfall to avoid 1
• Give fibrinogen concentrate or cryoprecipitate if fibrinogen <1 g/L 1
• Maintain platelets ≥75 × 10⁹/L with platelet transfusion as needed 1

Monitoring Protocol

• Recheck INR 15-60 minutes after PCC administration to assess degree of correction 2
• Monitor INR serially every 6-8 hours for the next 24-48 hours, as some patients require over a week to clear warfarin and may need additional vitamin K 2
• Perform urgent imaging (CT abdomen/pelvis) to quantify hemoperitoneum and identify bleeding source 1

Surgical Considerations

Indications for Intervention

• Hemodynamic instability despite aggressive resuscitation requires emergent exploratory laparotomy 1
• Ongoing transfusion requirements >4 units packed RBCs in 24 hours suggest need for surgical or interventional radiology control 1

Anticoagulation Resumption Strategy

Timing of Restart

• Resume anticoagulation after approximately 1 week once bleeding is controlled—the long-term risk of mechanical mitral valve thrombosis exceeds the risk of recurrent bleeding 1, 3
• Mechanical mitral valves carry extremely high thrombotic risk and can develop valve thrombosis within days of subtherapeutic anticoagulation 3

Bridging Protocol

• When restarting, initiate warfarin within 24 hours after bleeding stability is confirmed 3
• Start therapeutic doses of intravenous unfractionated heparin (UFH) when INR falls below 2.0, maintaining aPTT 60-80 seconds 3
• Continue IV heparin until INR reaches therapeutic range of 2.5-3.5 (target 3.0) on two consecutive measurements, then maintain both warfarin and heparin together for at least 24 hours before discontinuing heparin 3, 4
• Do NOT use LMWH or fondaparinux for bridging in the acute setting of recent major bleeding—they are contraindicated 1

Target INR for Mechanical Mitral Valve

• Maintain INR 2.5-3.5 (specifically targeting 3.0) for all mechanical valves in the mitral position, regardless of valve type 5, 3, 4
• The higher INR target compared to aortic mechanical valves reflects the greater risk of thromboembolic complications with mechanical valves in the mitral position 5

Critical Pitfalls to Avoid

• Never withhold PCC and vitamin K due to prosthetic valve concerns—life-threatening bleeding takes precedence over thrombosis risk 1, 2
• High-dose vitamin K1 alone is too slow (6-12 hours) and may create a hypercoagulable condition without concurrent PCC 1
• Both factor concentrates and vitamin K increase the risk of valve thrombosis, but in life-threatening bleeding, this risk is acceptable 1
• PCC use increases risk of venous and arterial thrombosis during recovery period—thromboprophylaxis must be considered as early as possible after bleeding control is achieved 2
• Monitor for prosthetic valve complications with cardiac imaging (transthoracic/transesophageal echocardiography) during the period of anticoagulation interruption 1