///2009 Abstract Details
2009 Abstract Details2018-05-01T17:45:11+00:00

SUCCESSFUL PLACEMENT OF A SUBARACHNOID BLOCK FOR CESAREAN SECTION IN A 19 YEAR OLD PRIMIGRAVIDA WITH ACQUIRED FACTOR VIII INHIBITOR.

Abstract Number: 218
Abstract Type: Case Report/Case Series

Timothy R Ball MD1 ; Lisa M Councilman MD2

Introduction: Factor VIII inhibitor is a rare acquired condition which impacts the coagulation cascade, potentially leading to life-threatening hemorrhage. Additional obstetric anesthetic concerns include eligibility for neuraxial blockade. We describe the successful placement of a subarachnoid block for a cesarean section in a 19-year-old African-American primigravida for failed induction of labor precipitated by preterm spontaneous rupture of membranes.

Case Report: Our patient developed factor VIII inhibitor following blood transfusions at the age of three after requiring a splenectomy for autoimmune lymphoproliferative disorder and sickle cell anemia trait. Followed closely by pediatric and adult hematology physicians, the patients factor VIII and factor VIII inhibitor levels were closely monitored throughout her pregnancy. The patients factor VIII level was 379 (normal range 50-150) and the factor VIII inhibitor level was zero at the time of presentation in labor. The patient declined offer of a remifentanil PCA for labor analgesia. At the time of cesarean section, the patient was offered a subarachnoid block (SAB), felt safe to perform with factor VIII inhibitor level of zero and a normal PTT. The SAB was performed without complication and the cesarean section proceeded without hemorrhagic complications. A thorough neurological exam was performed at 24 and 48 hours postoperatively and revealed no change from baseline in the patients lower extremity strength or sensorium. The patient was discharged home 48 hours after her cesarean section and was scheduled for follow-up with her hematologist, primary care physician, and obstetrician.

Discussion: Although quite rare, factor VIII inhibitor is a life-threatening condition due to hemorrhagic complications. As case in point, our patient developed a life-threatening hemorrhage from removal of a skin tag three years prior, leading to a cardiac arrest and requiring FFP and FEIBA for resuscitation. Literature is sparse in regards to anesthesia options for obstetric patients with this condition. This case report illustrates the potential acceptable use of neuraxial anesthesia in these patients. More dialogue and research are needed to state whether it is safe in all cases, but we propose that with a supranormal factor VIII level and a factor VIII inhibitor level of zero it is possible for experienced providers to perform safe neuraxial anesthesia in this patient population. We also recommend using the smallest size needle possible, minimizing the number of attemps, as well as continuing dialogue with the hematologist to monitor changes in factor levels.

SOAP 2009