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A CASE OF NEURAXIAL ANALGESIA IN A PATIENT WITH ANTITHROMBIN III DEFICIENCY RECEIVING ANTITHROMBIN III SUPPLEMENTATION DURING LABOR
Abstract Number: T-46
Abstract Type: Case Report/Case Series
Introduction: Hereditary antithrombin III (AT III) deficiency affects one in 2-5 thousand individuals. During pregnancy, this deficiency can result in a dramatic increase in the incidence of venous thromboemblism (1). Patients are often placed on anticoagulation during their pregnancy to avoid complications and anticoagulation is discontinued during labor. However, a significant risk of thromboembolism exist during labor. In an effort to decrease this risk some obstetricians have begun infusing recombinant AT III to laboring parturients. This therapy may complicate the placement of neuraxial analgesia as the patient may become coagulopathic. We report a case of epidural anesthesia successfully used in a laboring patient who received antithrombin III supplementation throughout labor and delivery.
Case Presentation: Our patient is a 32 yo G2P0000 at 37 weeks gestation, who was found to have antithrombin III deficiency during her coagulation workup following an IUFD at 40 weeks. At the onset of pregnancy the patient was started on twice daily low molecular weight heparin(LMWH). The patient was scheduled for induction of labor at 37weeks to allow for heparin discontinuation and the administration of AT III supplementation during labor. The patient was started on ATIII with a goal level of 80-120%. The first ATIII level was 110% (within the therapeutic range). Epidural catheter placement was planned at 24 hours following the last LMWH administration. At the time of neuraxial analgesia labs were drawn showing a normal platelet level and normal PTT. Uneventful labor epidural was placed with adequate labor analgesia and the patient had an uncomplicated labor course resulting in the vaginal delivery of a healthy male infant. The epidural catheter was removed one hour after the birth and the antithrombin III supplemenation was continued until the two dose of LMWH had been given. Close follow up of the patient’s neurologic and hematologic status was continued for greater than 48 hours following delivery.
Discussion: The incidence of venous thromboembolism in pregnant patients with hereditary antithrombin deficiency has been estimated to be about 70% (1). Replacement of antithrombin III during labor and discontinuation of heparin administration represents a new option for decreasing the risk of thromboembolism during labor, especially in high risk patients. The placement of epidural catheters while patients are receiving AT III supplementation may be challenging as patients may become supratherapeutic and therefore would have an increased risk of bleeding at time of epidural placement. Following ASRA guidelines and monitoring coagulation labs as well as AT III levels, we successfully used neuraxial anesthesia in our patient with no deleterious consequences (2).
References: 1) Pamnani, A et. al.(2010) J Clinical Anesthesia 22: 450-453 2) Horlocker, et. al. (2003) Reg Anesth Pain Med 28: 172-197 3)Perry, DJ (1994) Blood Rev 8: 37-5