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A Conundrum: General or neuraxial anesthesia and the use of ROTEM®
Abstract Number: T-02
Abstract Type: Case Report/Case Series
Introduction: Thrombocytopenia occurs in approximately 10% of all pregnancies.(1) However, there are no published studies demonstrating a specific platelet count that predicts the risk for neuraxial hematoma in obstetric patients. In the absence of clinical hemostatic anomalies, a minimum platelet count of 80 x 10^9/L has been suggested as sufficient for the safe initiation of neuraxial techniques.(2) We report the use of rotational thromboelastometry (ROTEM®) to guide the management of a patient with thrombocytopenia and multiple comorbidities that complicated the management of her pregnancy and delivery.
Case: A 29 year old primigravida at 36 weeks gestation with non-cirrhotic portal hypertension, esophageal varices, splenomegaly, steroid refractory thrombocytopenia and pseudocholinesterase deficiency presented with new onset severe hypertension, significant edema, a Mallampati III airway and a platelet count of 63 x 10^9/L. A multidisciplinary team identified concerns of increased bleeding risk from esophageal varices with Valsalva maneuvers, risk of spinal hematoma from neuraxial anesthesia with thrombocytopenia, airway management in a parturient with a potentially difficult airway, pseudocholinesterase deficiency and use of succinylcholine, and the patient’s strong reluctance to undergo intubation due to prior awareness under anesthesia. Although forceps delivery with pudendal block was contemplated, preoperative platelet transfusion and cesarean delivery under spinal anesthesia was performed. Baseline ROTEM parameters demonstrated decreased maximum clot firmness and increased clot formation time suggesting a defect in platelets. Following transfusion of two units of platelets, the ROTEM parameters improved and the platelet count increased to 88 x 10^9/L. Spinal anesthesia was performed using a 25 gauge Whitacre needle under ultrasound guidance. A cesarean section was undertaken with an estimated blood loss of 800 ml. The patient was monitored for signs of spinal hematoma. An 8 week postpartum follow up showed no complications related to the anesthetic or operative procedure.
Discussion: Although the platelet count and ROTEM® parameters that predict the ability to safely use neuraxial techniques in parturients has not been defined, the marked improvement of the maximum clot firmness and clot formation time combined with the improvement in the platelet count after a platelet transfusion optimized the risk benefit ratio of performing a spinal anesthetic. Future studies are needed to evaluate the use of ROTEM® in assessing the safety of neuraxial techniques in parturients with abnormal coagulation profiles.
1. Sainio S, Kekomaki R, Riikonen S, Teramo K: Maternal thrombocytopenia at term: a population-based study. Acta Obstet Gynecol Scand 2000; 79:744-9
2. van Veen JJ, Nokes TJ, Makris M: The risk of spinal haematoma following neuraxial anaesthesia or lumbar puncture in thrombocytopenic individuals. Br J Haematol 2010; 148:15-2