Epidural Post Platelet Transfusion – Good Analgesia or Taking a Risk?
Abstract Number: S-44
Abstract Type: Case Report/Case Series
Abstract: A 17 y/o primigravida was admitted for IOL at 38 weeks secondary to preeclampsia. She had a lifelong qualitative platelet disorder. Hematology workup defined this as an unnamed genetic qualitative platelet disorder, with normal counts, but mostly dysfunctional platelets. This case questions whether an epidural in a patient requiring platelet transfusion as part of her delivery plan is safe. Little literature exists to make recommendations and ASRA guidelines only discuss patients on anti-platelet medications, not with inherent dysfunction (1).
Hematology recommended 5 units platelets prior to delivery for adequate hemostasis. The patient desired a labor epidural and we felt that it could be safely performed because she would be receiving a platelet transfusion. Risks of transfusion would already be incurred as part of the delivery, and the platelet function should be adequate for an epidural.
At the onset of active labor the anesthesia team felt that an additional 5 units of platelets (total 10 units) were warranted given her preeclampsia. An epidural was placed at 8 cm cervical dilation and successful vaginal delivery of a baby boy (APGARS 8/9) followed (300mL EBL). She received 600 mcg PR of mesoprostol during delivery for hemostasis. Post-partum she had no fever, heavy bleeding, or neurologic signs of epidural hematoma. Her Hgb was 10.1 and although the platelet count was not documented, it may have been irrelevant given her qualitative disorder.
Discussion: Epidural hematoma is a rare and devastating complication of neuraxial anesthesia. The risk of epidural hematoma is difficult to assess and has been mainly based on case reports. Most report a risk of around 1 in 200,000 in parturients (2,3). With such a low incidence it is difficult to determine the relationship between epidural hematoma, regional anesthesia, and coagulopathy. Understanding the risk of hematoma, as it relates to platelets, also requires understanding of the coagulation system and how it changes during pregnancy. The hypercoagulable state further confounds this picture.
Predisposing risk factors for hematoma in parturients include gestational thrombocytopenia, pre-eclampsia with HELLP syndrome, thromboprophylaxis in pregnancy, and patients with preexisting coagulopathies. Thrombocytopenia is the most common hematologic disorder in pregnancy. Gestational platelet counts decrease until 26 to 32 weeks, but there is a compensatory increase in mean platelet volume (4,5). This suggests an increase in platelet consumption and reactivity. Typically, platelets return to normal 3-5 days postpartum. There is a risk of thrombocytopenia in subsequent pregnancies, as well (6).
1. ASA Update on Platelets, asahq.org 1/5/15
2. AANA 2014; 82(2): 127-130.
3. Chestnut’s Obstetric Anesthesia, 5th ed. Philadelphia 2014, p. 1047.
4. Obstet Gynecol 2000; 95:29-33.
5. Acta Obstet Gynecol Scand 2000;79:744-9.
6. Am J Hematol 1994;47:118-22.