SHM Converge Scientific Abstract ePoster Gallery-An Anticoagulation Dilemma: High Bleeding Risk in a Hypercoagulable State

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This case describes a 65-year-old woman with antiphospholipid syndrome (APLS), prior recurrent DVTs, miscarriages, and chronic warfarin use who presented after syncope and a fall with head trauma. She was found to have an acute subdural hematoma and, simultaneously, a new non-occlusive left femoral DVT. Her hospital course became more complicated by thrombocytopenia, coagulopathy, and later evidence of a small acute ischemic stroke. Heparin-induced thrombocytopenia was excluded.<br /><br />Because of severe thrombocytopenia and active intracranial bleeding, all anticoagulation was initially stopped. She could not receive an IVC filter. While anticoagulation was held, she developed a pulmonary embolism with right ventricular strain and McConnell’s sign, illustrating the difficulty of balancing extreme bleeding risk against very high thrombotic risk.<br /><br />Workup supported secondary immune thrombocytopenia (ITP), likely in the setting of autoimmune disease/APLS, based on giant platelets, positive platelet antibodies, and no other clear cause. She was treated with dexamethasone and IVIG, later romiplostim, and a dose of rituximab. Her platelet count improved rapidly, allowing anticoagulation to be restarted with heparin and then bridged back to warfarin before discharge.<br /><br />The main takeaway is that patients with APLS and ITP can pose a major anticoagulation dilemma: they are at high risk for both thrombosis and catastrophic bleeding. When anticoagulation is contraindicated, it should be held, but management requires close reassessment, multidisciplinary input, and shared decision-making.

Asset Subtitle

Vihanga Perera

Meta Tag

Author List Herman Davidovics, Pritika Sharma, Ronald Cho, Vihanga Perera, Wei Tang

Category Clinical Vignettes

Concept Anticoagulant Management

Concept Antiphospholipid Antibody Syndrome

Concept Subdural Hematoma

Concept Thrombocytopenia

Concept Deep Vein Thrombosis

Distinguished Non-Finalist

Presenter Organization Westchester Medical Center

Presenting Author Vihanga Perera

Track Adult

Keywords

antiphospholipid syndrome

immune thrombocytopenia

subdural hematoma

deep vein thrombosis

pulmonary embolism

warfarin

thrombocytopenia

intracranial bleeding

heparin-induced thrombocytopenia

anticoagulation dilemma

Anticoagulant Management

Antiphospholipid Antibody Syndrome

Subdural Hematoma

Thrombocytopenia

Deep Vein Thrombosis