PB1376 - Periprocedural hemostatic outcomes in bleeding of unknown cause

Background: Bleeding of unknown cause (BUC) is a diagnostic category encompassing patients with a clear bleeding phenotype but without identifiable abnormality on hemostatic testing. The optimal management of BUC patients prior to invasive procedures is uncertain.

Aims: Our objective is to characterize periprocedural hemostatic prophylaxis and bleeding outcomes in BUC.

Methods: We conducted a retrospective cohort study of BUC patients using the University of North Carolina’s American Thrombosis and Hemostasis Network dataset and supplemental chart review. Adult patients who received a BUC diagnosis after completion of a structed bleeding assessment and advanced diagnostic testing were included. Following diagnosis of BUC, subsequent procedures and deliveries, hemostatic prophylaxis, and bleeding complications were analyzed.

Results: Seventy BUC patients were identified with mean age 44 years (SD=17) and mean Molecular and Clinical Markers for the Diagnosis and Management of Type 1 VWD (MCMDM-1) bleeding score 9.4 (SD=4.3); the majority of patients were female (89%). Seventy-seven surgical procedures (51 minor and 26 major) and 6 deliveries were performed in the cohort. Hematology recommendations for periprocedural hemostatic prophylaxis (with antifibrinolytics, DDAVP, platelets, and/or cryoprecipitate) was obtained and adhered to in 75% of procedures (58/77) and all deliveries. Twenty-five percent of procedures (19/77) were conducted without prior hematology consultation and no prophylaxis was given. Platelet administration was associated with procedure type (major vs. minor, OR=6.36, 95%CI=2.2–18.37), but not bleeding score. Major or clinically relevant minor bleeding occurred in 5.4% (3/56) of procedures with prophylaxis and 10.5% (2/19) of procedures without prophylaxis. Postpartum hemorrhage occurred in 40% (2/5) of deliveries.

Conclusion(s): In this single institution experience, we observe that BUC patients commonly undergo procedures without hematology guidance and that procedures with hemostatic prophylaxis had half the proportion of bleeding events compared to procedures without prophylaxis. Multi-center and prospective analyses are needed to clarify role of periprocedural hemostatic prophylaxis in BUC.