Risk factors for thrombolysis: ============================== Absolute (Sherry) - actively bleeding - intracranial vascular disorders (CVA or TIA within two months, intracerebral tumor, intracerebral AVM) Relative (Sherry) - Age > 70 - large abraded wounds - major surgery or deep closed biopsies within 10 days - severe HTN (DBP > 110) - increased bleeding risk, e.g., platelet or clotting defect, severe liver failure, advanced uremia Others: - significant internal bleeding within past six months (Goldhaber 1986) - hematocrit less than 30% (Goldhaber 1986) - pregnancy (Goldhaber 1986) - thoracic or neurosurgery at any time (Verstraete); neurosurgery within 2 months (Elliot) - CVA or TIA within six months (Verstraete) - major head injury in past month (Verstraete) - known active peptic ulcer (Verstraete) - menstruation (Elliot) but see below: - recent streptococcal infection (for streptokinase; Elliot) - previous streptokinase therapy within six months (for streptokinase; Elliot) - known malignant disease (Arnesen) > Does anyone know if active menstruation is a contraindication for > thrombolysis. It seems like it would be hard to tamponade the inside of > the uterus. Firm guidelines do not exist but numerous case reports indicate that it is probably safe (1,2,3). It is not listed among the traditional contraindications. H. Louzon MD (1) Sekyema YF, Baltazar RF Is thrombolytic therapy safe during active menstruation? J Emerg Med 1995 May-Jun;13(3):345-8 A 39-year-old female presented to the Emergency Department during the fourth day of menstruation and within 2 hours of the onset of chest pain associated with dyspnea, diaphoresis, and emesis. An electrocardiogram showed acute inferior myocardial infarction and serial CPK enzyme levels peaked at 958 IU/L with 9% MB fraction. Along with aspirin and intravenous nitroglycerin, the patient was given thrombolytic therapy consisting of tPA with an initial bolus of 35 units, followed by 65 units infused within 60 minutes together with heparin 5000 units intravenous bolus, and 1000 units/hour maintenance infusion for 5 days. The menses were prolonged 1 day longer than her usual 5 days; however, there was no increase in the amount of bleeding during any day. The hemoglobin dropped from 12.5 G/dl to 11.3 G/dl in the first 6 hours, but remained stable thereafter. This initial drop in hemoglobin was considered a dilutional effect of 1.5 L of normal saline the patient received intravenously during that period. Although no available guidelines exist regarding the safety of thrombolytic agents during active menstruation, this case report and a few others reported in the literature suggest that normal menstruation is not a contraindication to thrombolytic therapy during acute myocardial infarction. (2) Lee DW, Garza JL Front-loaded infusion therapy of rT-PA during active menstruation. A case report. Angiology 1994 Apr;45(4):311-4 The authors report use of intravenous (IV) tissue plasminogen activator (TPA) to treat acute anterior wall myocardial infarction in a forty-two-year-old woman during the active menstrual period. The patient received the TPA with the front-loading system with excellent result. Hemoglobin remained unchanged. This case demonstrates that TPA infusion can be used in a menstruating woman without causing a dangerous hemorrhage. (3) Puzio B, Polonski L, Kusnierz B [Treatment of recent myocardial infarction during menstruation--presentation of a case] Kardiol Pol 1993 Aug;39(8):113-4 A young woman was admitted because of recent myocardial infarction (MI). Although she displayed menstruation bleeding, thrombolytic therapy with tpA was instituted. This resulted in full reperfusion and uneventful clinical course of MI. There was no prolongation of menstruation. Fibrinolytic treatment in women with MI and menstruation seems to be a safe procedure. >Does anyone know if active menstruation is a contraindication for >thrombolysis. It seems like it would be hard to tamponade the inside of >the uterus.>-- >Daniel E. Kates, M.D.>dkates@primenet.com >Thunderbird Samaritan Medical Center>Phoenix, Arizona>U.S.A.> Yes: it is probably not. Both Data for for TPA use (1) in 17 women, from Gusto in 12 women (2), and various cases did not show anything more than moderate increase in blood flow. It is postulated (1), (3), than the regulation of flow is not dependant of clotting factors, but rather platelet (1), arterial constriction,myometrial contraction and tissue regeneration (1), and a vsospastic response to local prostaglandins (3). The risk seems not increased but, naturally, for the few patient studied no conclusion could be drawn in relation to mortality, although there was 0/12 mortality in Gusto compared to a general 11.3% in women (but only 1.8% in premenopausal) (2). So, we probably go for it. Regards, Alain Vadeboncoeur MD. (1) SAFETY OF THROMBOLYTIC THERAPY IN NORMALLYMENSTRUATING WOMEN WITH ACUTE MYOCARDIAL INFARCTION Lanter, P.L., et al, Am J Cardiol 74(2):179, July 15, 1994 BACKGROUND: There is currently scant data regarding use of thrombolytic agents in womenwith acute myocardial infarctions (AMIs) occurring concomitantly with "active bleeding" in the formof normal menstruation. METHODS: The authors, from the Medical College of Virginia, measured hemoglobin levels onadmission and three days after therapy in three women treated with standard or accelerated dosedrecombinant tissue plasminogen activator (rTPA) or standard IV streptokinase in addition to aspirinand IV heparin for AMI during menstruation. Data from Genentech, Inc., the manufacturers ofrTPA, were also analyzed for 14 additional women treated during active menstruation (admissionand nadir hemoglobin levels were available for only three). Hemoglobin levels from these six patientswere compared with those from a retrospective control group of ten nonmenstruating women belowthe age of 60 who were treated with thrombolytic agents for AMI. RESULTS: There were no major adverse events in the 17 women treated with thrombolytic agentsduring menstruation, although seven reported a slight increase in flow. There were no significantdifferences between the actively menstruating and control patients in the decrease in hemoglobinlevels from admission to the third hospital day (19.6% in the former and 17.7% in the latter). CONCLUSIONS: Menstrual bleeding is limited by platelet plugs only during the first 20 hours. It issubsequently regulated by mechanisms unrelated to the clotting cascade (arterial constriction,myometrial contraction and tissue regeneration). Thrombolytic therapy appears to be safe for use innormally menstruating females, especially after the first 20 hours of menstruation. 12 referencesCopyright 1994 by Emergency Medical Abstracts - All Rights Reserved 11/94 - #3 (2) TREATING MENSTRUATING WOMEN WITH THROMBOLYTIC THERAPY: INSIGHTS FROM THE GLOBAL UTILIZATION OF STREPTOKINASE AND TISSUE PLASMINOGEN ACTIVATOR FOR OCCLUDED CORONARY ARTERIES (GUSTO-I) TRIAL Karnash, S.L., et al, J Am Coll Card 26(7):1651, December 1995 BACKGROUND: Women account for 33% of the estimated 1.5 million acute myocardialinfarctions (AMIs) occurring each year in the U.S.; about one-fifth of these women are below theage of 65. It may be estimated that between 7-21% of premenopausal women with AMIs could bemenstruating on presentation. METHODS: This study, from Duke University Medical Center, and funded by grants from Bayer,CIBA-Corning, and Genentech, examined findings in twelve North American women participating inthe GUSTO-I trial who received thrombolytic therapy during menstruation. RESULTS: The 30-day mortality rate was 0% in the menstruating women, 1.8% in premenopausalnonmenstruating women, and 11.3% in all women participating in GUSTO-I. The one-year mortalityrates were 0%, 2.7% and 14.6%, respectively, and the frequency of strokes was 0%, 0.8%, and2.1%, respectively. None of the menstruating women developed severe, hemodynamically significantbleeding, compared with 2% of the women in the remaining two groups. Moderate bleedingrequiring transfusion occurred in 3/12 (25%) of menstruating women, 11% of nonmenstruatingpremenopausal women, and 17% of all women participating in GUSTO-I. CONCLUSIONS: Based on their findings, combined with anecdotal case reports of twelveadditional menstruating women treated with thrombolytic agents, the authors suggest that, while therisk of moderate bleeding may be increased in menstruating women with AMIs treated withthrombolytic agents, menstruation should not be considered a contraindication to thrombolytictherapy. 20 references Copyright 1996 by Emergency Medical Abstracts - All Rights Reserved 4/96 - #9 (3) IS MENSTRUATION A CONTRAINDICATION TO THROMBOLYTICTHERAPY? Conti, C.R., Clin Cardiol 15:625, 1992 The author, editor in chief of the cited journal, discusses use of thrombolytic agents in activelymenstruating women. He points out that heparin and coumadin are often given during menstruation inthe practice of obstetrics and gynecology. In these situations, increased menstrual bleeding isgenerally managed with estrogens. The effects of this practice during an evolving MI are unknown.Unlike uterine bleeding due to other causes (such as a tumor), menstrual bleeding is related to a vasospastic response to local prostaglandins, and control of bleeding in these circumstances is notnecessarily related to clot formation. To date, there have been only four English-language reportsregarding thrombolytic therapy during menstruation. Two case reports documented no majorcomplications in one women treated with intracoronary streptokinase and one treated with IV tPAand heparin. One additional article indicated that menstruation should not constitute acontraindication to thrombolytic therapy but provided no data to support this recommendation. Aneditorial supporting the use of thrombolytic therapy during menstruation suggests that immediateangioplasty may be preferable unless inordinate delays are anticipated. Information from Genentech,Inc., a tPA manufacturer, indicated that increased flow without major bleeding complications wasnoted in most of the 21 anecdotal reports that they have received regarding use of tPA inmenstruating women. They advise close monitoring of vaginal bleeding if thrombolytic therapy isemployed during the menses. Considering the morbidity and mortality of AMI versus that ofincreased uterine bleeding, the author suggests that thrombolytic therapy is worth using in thesesituations. 4 references Copyright 1993 by Emergency Medical Abstracts - All Rights Reserved 01/93 - #3