High-Dose of Tranexamic acid for Managing Excessive Postpartum Hemorrhage after a Poisonous Snake bite in the Third Trimester of Pregnancy

A 27-year-old pregnant woman presented with pain, swelling, and bleeding from her left foot and reduced fetal movement after enduring a snake bite. 

The lady was 30 weeks pregnant and had had four pregnancies with three live births in the past. Two of her living children did not require antenatal care. The snake was unidentified. 

On examination, she was conscious and stable. Two bite marks were observed on the sole of her left foot, spaced 2 cm apart. There were no signs of spontaneous bleeding or neurotoxic envenomation. Abdominal examination indicated a uterus size of 28 weeks, but fetal heart sounds were not detectable. 

Initial coagulation tests showed abnormalities, and ultrasonography confirmed intrauterine fetal demise.

Treatment involved the administration of polyvalent anti-snake venom along with conservative measures. The patient received 17 units of fresh frozen plasma over ten days for coagulopathy, but her condition did not improve. 

Regular laboratory tests, vital sign monitoring, and clot retraction tests were performed. She spent ten days in the Medical Intensive Care Unit (MICU) and eventually went into labor, delivering a macerated stillborn baby weighing 2.1 kg. Postpartum hemorrhage, which was unresponsive to traditional methods, occurred despite a fully retracted uterus and the exclusion of traumatic causes.

Aggressive treatment included high-dose tranexamic acid, blood products, and intravenous fluids, which led to the cessation of bleeding within 10 minutes of the bolus tranexamic acid dose. Further administration of blood products stabilized her condition, and her coagulation profile improved.

Snake bites during pregnancy, particularly in the third trimester, carry potential risks to the mother and fetus. Early diagnosis, prompt medical intervention, and access to anti-snake venom, along with comprehensive care, are crucial in managing such cases and preventing adverse outcomes for both the mother and the fetus.

Source: Das D, Baidya JL. Indian Obstet Gynaecol. 2023 Apr 1;13(2).