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


Abstract Number: 86
Abstract Type: Case Report/Case Series

Krzysztof M. Kuczkowski M.D.1

Introduction: The risk of central neuraxial blockade and perioperative bleeding in patients with coronary artery disease (CAD) and coronary artery stents in situ treated with newer antiplatelet drugs (e.g., clopidogrel) usually in combination with aspirin is unclear (1). Clopidogrel (Plavix, Bristol-Myers Squibb Co., New York, NY, USA) demonstrates both time-and dose-dependent effects; steady state for clopidogrel is achieved within 7 days. Labeling recommends, "if a patient is to undergo elective surgery, and an antiplatelet effect is not desired, clopidogrel should be discontinued 7 days prior to surgery." I herein report a case of a parturient with CAD, status post recent coronary artery stenting (on clopidogrel and aspirin) awaiting planned induction of labor who developed severe bleeding following minor nonobstetric surgery a day prior to her scheduled delivery. Despite adhering to standard guidelines concerning administration of aspirin peripartum (perioperatively) and stopping the clopidogrel more than 7 days before the planned induction of labor and anesthetic, the patient developed bleeding after otherwise minor cosmetic surgery. In fear of an epidural-spinal hematoma no neuraxial blockade was performed for delivery.

Report of case: A 36-year-old female at 38 weeks of multiple (twin) gestation, coexisting CAD, and history of peripartum CAD dissection with recent stenting of her left anterior descending (LAD) artery was admitted to our Labor and Delivery Suite with bleeding following minor cosmetic surgery (mole resection) a day prior to her planned induction of labor. This bleeding complication was reported despite the fact that her combination antiplatelet drug therapy with clopidogrel and aspirin was used for appropriate indications and duration, and discontinued peripartum (perioperatively) according to the current guidelines (1) and drug labeling. To the best of this authors knowledge, this is the first reported case of clopidogrel and aspirin antiplatelet drug therapy-related complication in the peripartum period. It is tempting to speculate that superficial (and easy to control) forearm bleeding following moles resection might have prevented more serious (and difficult to control) complications (neuraxial bleeding) following administration of epidural labor analgesia.

Discussion: Maternal heart disease complicates 0.2-3% of pregnancies. As more women delay childbearing to later reproductive years, CAD in pregnancy is becoming increasingly prevalent. New trends in interventional cardiology, e.g. the increasing practice of coronary intervention with stent implantation and the prolonged use of dual antiplatelet therapy - usually a combination of clopidogrel and aspirin - has created new peripartum dilemma between stent thrombosis, due to preoperative discontinuation of antiplatelet drugs, and surgical bleeding and neuraxial hematoma by continuation of drug therapy.

References: 1. Reg Anesth Pain Med 2003; 28:172-97

SOAP 2009