Clinical Practice FAQs
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Common clinical questions with answers by experts from the SOAP Education Committee. More content is coming soon. Submit your questions to firstname.lastname@example.org
Neuraxial Anesthesia – Coagulopathy
Thrombocytopenia is commonly encountered in the obstetric population, with ~2% of parturients demonstrating platelet counts less than 100,000/mm3.1,2 Given the theoretical risk of epidural hematoma, thrombocytopenia is considered a relative contraindication to neuraxial anesthesia. Several studies have attempted to delineate the platelet count at which it is “safe” to attempt a neuraxial technique. Recent evidence suggests the risk of epidural hematoma is extremely low in parturients with platelet counts > 70,000/mm3.1-3 The risk of epidural hematoma with platelet counts < 70,000/mm3 remains poorly defined.
The etiology of thrombocytopenia and considerations for platelet function should be considered when making a decision for neuraxial anesthesia. The use of platelet function analysis (PFA), thromboelastography, or thromboelastometry to guide a decision for neuraxial analgesia and anesthesia placement is controversial.
–Emily Baird, MD
Oregon Health Sciences University
- Lee LO, Bateman BT, Kheterpal S, et al. Risk of epidural hematoma after neuraxial technique in thrombocytopenic parturients. Anesthesiology 2017; 126: 1053-63.
- Levy N, Goren O, Cattan A, et al. Neuraxial block for delivery among women with low platelet counts: a retrospective analysis. Int J Obstet Anesth 2018; 35: 4-9.
- Goodier CG, Lu JT, Hebbar L, Segal BS, Goetz L. Neuraxial anesthesia in parturients with thrombocytopenia: a multisite retrospective cohort study. Anesth Analg 2015; 121: 988-91.
External Cephalic Version
External cephalic version (ECV) is encouraged by ACOG as a method to reposition the breech fetus to a vertex presentation before the onset of labor with the hope of avoiding a Cesarean delivery and facilitate a vaginal one. There is evidence1 that neuraxial (spinal, combined spinal-epidural (CSE), and epidural) analgesia and/or anesthesia improves the success rate of the ECV. While there are numerous studies demonstrating this effect, optimal dosing has not been fully established. A recent randomized study by Chalifoux2 et al. did not show any increased success with intrathecal bupivacaine doses greater than 2.5mg as part of a CSE with intrathecal fentanyl 15mcg. Carvalho and Bateman3 suggest, however, that the optimal dose for a given patient may depend on the clinical plan. If the plan is discharge to home after ECV, then lower dose bupivacaine may be best. If the plan is delivery immediately after ECV (either Cesarean or induction depending on the ECV outcome), then larger dose (7.5mg or 10mg) bupivacaine may be best.
— Stephanie Goodman, MD
Columbia University Medical Center
- Magro-Malosso ER, Saccone G, Di Tommaso M, Mele M, Berghella V: Neuraxial analgesia to increase the success rate of external cephalic version: A systematic review of meta-analysis of randomized controlled trials. Am J Obstet Gynecol 2016; 215: 276-86.
- Chalifoux LA, Bauchat JR, Higgins N, Toledo P, Peralta FM, Farrer J, Gerber SE, McCarthy RJ, Sullivan JT: Effect of intrathecal bupivacaine dose on the success of external cephalix version for breech presentation: A prospective, randomized, blinded clinical trial. Anesthesiology 2017; 127; 625-32.
- Carvalho B, Bateman BT: Not too little, not too much: Finding the goldilocks zone for spinal anesthesia to facilitate external cephalic version. Anesthesiology 2017; 127; 596-8.
For more information:
- Please listen to Dr. Carolyn Weiniger’s excellent podcast on ECV. https://www.openanesthesia.org/podcasts/soap-obstetric-anesthesia-podcast/
The transversus abdominis plane (TAP) block is a regional technique providing sensory blockade of the abdominal wall. Analgesia is achieved by targeting anterior rami of spinal nerves that travel between the internal oblique and transversus abdominis muscles. Several variations exist. 1
TAP blocks may be most beneficial when intrathecal morphine is contraindicated or solely inadequate. As part of an opioid-sparing, multimodal analgesic regimen, TAP blocks may be performed at any point during the perioperative period. 2,3 The technique is considered low risk and with few complications. Unable to block visceral pain, TAP blocks cannot provide intra-abdominal surgical anesthesia alone.
–Kristin Brennan, MD
Penn State Health System
- Ng SC, Habib AS, Sodha A et al. High-dose versus low-dose local anaesthetic for transversus abdominis plane block post-caesarean delivery analgesia: a meta-analysis. Br J Anaesth 2018: 120(2): 252-263.
- Mcdonnell JG, Curley G, Carney J, et al. The analgesic efficacy of transversus abdominis plane block after caesarean delivery: a randomized controlled trial. Anesth Analg 2008;106:186 – 191.
- Jadon A, Jain P, Chakraborty S et al. Role of ultrasound guided transversus abdominis plane block as a component of multimodal analgesic regimen for lower segment caesarean section: a randomized double blind clinical study. BMC Anesthesiol 2018; 18; 53.
For more information:
- Abdallah FW, Halpern SH, Margarido CB. Transversus abdominis plane block for postoperative analgesia after caesarean delivery performed under spinal anesthesia? A systematic review and meta-analysis. Br J Anaesth 2012; 109(5): 679 – 87.
- Blanco R, Ansari T, Girgis E. Quadratus lumborum block for postoperative pain after caesarean section. Eur J Anesthesiol 2015; 32:812 – 818.
- Young MJ, Gorlin AW, Modest VE and Quraishi SA. Clinical implications of the transversus abdominis plane block in adults. Anesthesiol Res Pract 2012; 2012: 1-11.