Development of antibodies to topical bovine thrombin after abdominal hysterectomy - A case report

BACKGROUND: Topical thrombin spray is frequently used as a hemostatic agent in surgery, particulary following cardiovascular, orthopedic and neurologi c surgery. Acquired coagulation factor inhibitors to thrombin and factor V may develop following gynecologic surgery with repeat topical thrombin use. CASE: A 45-year-old woman underwent total abdominal hysterectomy/bilateral salpingo-oophorectomy. Her past medical history included idiopathic thrombo cytopenic purpura and Marfan's syndrome and past surgery included splenecto my and aortic valve replacement with a three-vessel coronary artery bypass graft. She was converted from Coumadin (DuPont Pharmaceuticals, Wilmington, Delaware) to heparin preoperatively, and heparin was stopped six hours bef ore surgery, with norm malization of her prothrombin time (PT) and partial thromboplastin time (PTT). Topical bovine thrombin spray was applied to the surgical field in anticipation of early resumption of heparin anticoagulat ion. Seven days after surgery, after recovering from some acute bleeding pr oblems, the patient began to have elevation of her PT in spite of being off Coumadin for 10 days. Her PT and international normalized ratio (INR) cont inued to rise, reaching peak values of 31.4 and 6.99, respectively. A mixin g study did not correct the problem, confirming the presence of coagulation inhibitors. The patient was given globulins and corticosteroids, and intra venous immunoglobulins and corticosteroids, and her PT/PTT and INR values s lowly normalized. CONCLUSION. Acquired coagulation factor may develop following gynecologic s urgery with topical thrombin use. This potential complication should be str ongly considered in any patient prior to using topical bovine thrombin, esp ecially those with a prior exposure or history of surgical procedures in wh ich bovine thrombin is commonly used.