Endogenous Heparinoids Induced Massive Hemorrhage Postoperatively Following THA

Case Report

A 64-year-old presented with right hip pain of 6 years’ duration. The pain did not radiate, and there was no fever or swelling. During this period, the pain was intermittent and increased with walking. In the past year, the pain was accompanied by a limp.

Preoperative pelvis anteroposterior radiograph showed narrowing of joint space, osteophyte formation and cystis degeneration of the femoral head surrounded by bony sclerosis, without obvious collapse of femoral head (Figure ), the diagnosis was osteoarthrosis in the right hip joint. The patient had chronic superficial gastritis, with no history of nonsteroidal anti-inflammatory drug use, allergic or hemorrhage history, and no chronic liver, kidney, or cardiovascular disease.

Figure 1:. Preoperative Radiograph Shows Narrowing of Joint Space, Osteophyte Formation and Cystis Degeneration of Femoral Head Surrounded by Bony Sclerosis, Without Obvious Collapse of the Femoral Head.

The patient’s height and weight were 150 cm and 45 kg, respectively. Her blood pressure on admission was 128/76 mm Hg. Preoperative laboratory tests were normal, including hepatic and renal function and coagulation test. Blood tests revealed hemoglobin was 135 g/L, hematocrit was 0.38, and platelet was 85×109/L, a little lower than normal.

Total hip arthroplasty was performed via a posterolateral approach with a 50-mm uncemented pinnacle acetabular cup, 2 acetabular screws, size 10 uncemented corail femoral prosthesis, size +1 neck length, and a 32-mm ceramic head (Johnson & Johnson/DePuy, Warsaw, Indiana). The operation time was 90 minutes, with no obvious vascular damage, and intraoperative bleeding was 400 mL.

In the first 10 hours postoperatively, the drainage volume decreased slowly, with the total volume 710 mL (Figure ), and the blood pressure was 84~92/45~56 mm Hg. The initial dose of 0.3 mL Fraxiparine (J20090006; Glaxo Wellcome Rroduction, France) was administered 10 hours postoperatively according to the protocol for preventing deep venous thrombosis. Platelet was 63×109/L before administration of Fraxiparine. The drainage volume increased gradually but the coagulation test was normal; erythrocyte suspension and plasma were supplied consecutively, and tranexamic acid, carbazochrome sodium, and sulfonate reptilase were applied at this time.

Figure 2:. Plot of Drainage Volume According to Time. At the First 10 Hours, the Drainage Volume Decrease Slowly. The Patient Receives Low-Molecular-Weight Heparin (LMWH) at the 10th Hour, Then the Drainage Volume Increase Gradually and the Massive Hemorrhage Occurs 10 Hours Later. After Administration of Protamine (at the 31st Hour), the Drainage Volume Decreases Sharply. Additionally, No Big Changes Are Detected in Platelet and TT Until 18 Hours After Administration of LMWH.

Ten hours after administration of Fraxiparine, the drainage volume increased sharply and maintained at a high level (Figure ). Cryoprecipitate and fibrinogen were then administered urgently. Prosthesis loosening or concealed fracture surrounding the prosthesis intraoperatively and disseminated intravascular coagulation or von Willebrand disease were suspected but radiographs revealed no abnormality (Figure ). The coagulation test found that prothrombin time and activated partial thrombin time were 16.9 seconds (normal range, 9.6~12.8 seconds) and 61.5 seconds (normal range, 20.0~40.0 seconds), respectively. Thrombin time was 19.9 seconds (normal range, 14.0~22.0 seconds). Negative result of plasma protamine paracoagulation test certified that there was no disseminated intravascular coagulation. Factor VIII:C,Vwf:Ag and Vwf: RCo were negative, indicating von Willebrand disease was not possible.

Figure 3:. Postoperative Radiograph Shows the Prosthesis Has Excellent Position and There Is No Fracture.

Eighteen hours after administration of Fraxiparine, the thrombin time increased, up to 120 seconds, and platelet reduced to 34×109/L, but no big change was detected in activated partial thrombin time and prothrombin time. Platelet transfusion was considered.

With all possible reasons excluded, bleeding was likely induced by exogenous LMWH or endogenous heparinoids. Twenty-one hours after the administration of LMWH, protamine was applied. The drainage volume decreased sharply to 20 mL per hour in 2 hours. Two units of platelet was still used 5 hours after bleeding cessation.

The administration of Protamin continued for 2 days. The total bleeding volume was up to 4000 mL and total urine volume was >30 mL per hour. The result of concentration of blood heparinoids was 3200 ng/mL, far more than the upper limitation of 600 ng/mL, confirming the massive hemorrhage was induced by endogenous heparinoids. The patient recovered quickly and was discharged 14 days later.

Discussion

Heparin can be classified as exogenous and endogenous, and can inhibit coagulation through anti-coagulator factor Xa. Endogenous heparinoids are glycosaminoglycans that are widely distributed in mammal tissues and appear to be synthesized by all type of cells, especially the hepatocyte and endothelial cells, but are main constituents of the vessels and can be linked to the endothelium. ⁴ Being natural anticoagulants, all these glycosaminoglycans have anticoagulation properties and help maintain coagulation hemostasis at the endothelial surface, and heparin sulfate is the most important glycosaminoglycans. ⁵

We excluded potential reasons for hemorrhage including disseminated intravascular coagulation, femoral or acetabular fracture, low platelet, deficiency of coagulator factors and von Willebrand disease. Figure demonstrates the whole bleeding course, bleeding was almost ceased before the administration of LMWH, and the drainage gradually increased after the injection of LMWH; the massive hemorrhage observed in our patient can be linked to the administration of Fraxiparine. The effective reversible action of protamine administration suggested that the bleeding was induced by a heparin-like substance.

As this patient had received LMWH, it is hard to determine whether bleeding was caused by exogenous LMWM or endogenous heparinoids. However, there was no liver disease, the elimination of exogenous LMWH must be normal, it is known that the peak concentration occurred 4~6 hours after administration of the Fraxiparine subcutaneously, and the demiperiod of single dose of Fraxiparine was 10 hours. If the massive hemorrhage was induced by exogenous LMWH, thrombin time would decrease gradually with the excretion of LMWH. In contrast, the massive bleeding occurred 10 hours after administration of Fraxiparine, and the thrombin time was normal during this time. Furthermore, the high concentration of heparan sulfate confirmed our speculation.

Both exogenous and endogenous heparinoids are cleared by the liver, and the elevated levels of endogenous heparinoids have been reported and well discussed in cirrhotic patients. ^6–9 Senzolo et al ⁹ found the presence of endogenous glycosaminoglycans in patients with liver disease may contribute to thrombin coagulopathy. Comparing patients who had cirrhosis without recent variceal bleeding, Mckee et al ⁶ found increased endogenous heparinoids concentration in cirrhotic patients who had recent variceal bleeding, and a high level of endogenous heparinoids was considered as the possible reason for bleeding.

The presence of endogenous heparinoids in our patient is demonstrated. It has been postulated that endotoxins and inflammation due to infection could release heparinoids from the endothelium, hepatocyte, and mast cells. ^10,11 Activation of macrophage or endothelium following ischemic reperfusion injury is another possible source of increased heparinoids. ¹² Additionally, Nader et al ¹³ found that the synthesis of heparin sulfate increased when the endothelial cells were exposed to LMWH, ie, LMWH could induce the production of heparan sulfate in endothelial cells, and the antithrombotic activity of LMWH “in vivo” could be related, at least in part, to the production of peculiar heparin sulfate by endothelial cells.

Although no direct evidence was detected, a high level of endogenous heparinoids were detected in our patient, and the massive hemorrhage was associated with administration of LMWH. The administration of LMWH combined with continuous low blood pressure caused by surgery and massive bleeding, which resulted in low perfusion and inflammation in micro-circulation, induced endogenous heparinoid synthesis in endothelial cells, and elevated concentration of endogenous heparinoids in blood leaded to more severe bleeding.