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Safety of neuraxial anesthesia in a preeclamptic patient receiving recombinant anti-thrombin infusions
Abstract Number: SA-66
Abstract Type: Case Report/Case Series
A 34 year-old G4P2012 at 34 weeks gestation with severe preeclampsia, characterized by severe range blood pressures and headaches, presented for Cesarean section (CS). She was enrolled in the PRESERVE-1 (Prospective Randomized Evaluation of the Safety and Efficacy of Recombinant Antithrombin in Very Preterm Preeclampsia) clinical trial, which involved daily infusion of either recombinant anti-thrombin (rhAT) or placebo up until 34 weeks gestation. Her final “blinded” infusion had been stopped just 5 hours prior to deciding to proceed with CS, thus complicating her anesthetic plan. The obstetrician requested a spinal anesthetic, insisting that the (potential) rhAT infusion would not pose any increased risk for coagulopathy, or possible epidural hematoma. The patient’s hematocrit was 32.4, and platelets 273; no coagulation studies were available.
Preeclampsia is a pregnancy-specific disorder affecting approximately 4% of all pregnancies, characterized by hypertension (>140/90) and proteinuria with or without other systemic symptoms. While it is a leading cause of maternal and perinatal morbidity and mortality, its precise etiology and optimal treatment strategy remain uncertain, with delivery being the only effective treatment modality (1). Patients with preeclampsia are suspected to have aberrant trophoblastic invasion of the placenta into the myometrium, along with endothelial cell dysfunction, and activation of the coagulation cascade with decreased antithrombin levels. Studies have been investigating various ways to halt the progression of preeclampsia, thereby delaying delivery, allowing more time for the fetus to develop in-utero. Plasma-derived anti-thrombin has been administered as a treatment for preeclampsia in several small clinical trials with success in improving both perinatal and maternal outcomes. PRESERVE-1 is another such trial, assessing the pharmacokinetic properties and safety of rhAT in preterm severe preeclampsia (2).
To plan for the safest course of action in this patient, coagulation studies were obtained, which returned within normal range. Rotational thromboelastometry (ROTEM) was also tested, which resulted in normal coagulation for pregnancy. The patient then underwent a safe and successful spinal anesthetic, followed by uncomplicated CS. She was discharged home in good condition on post-operative day 7.
1) Chestnut, David H. Chestnut's Obstetric Anesthesia: Principles and Practice. 4th ed. Philadelphia: Mosby/Elsevier, 2009. Print.
2) Paidas, Michael J., Bahaeddine M. Sibai, Elizabeth W. Triche, Johan Frieling, and Simon Lowry. "Exploring the Role of Antithrombin Replacement for the Treatment of Preeclampsia: A Prospective Randomized Evaluation of the Safety and Efficacy of Recombinant Antithrombin in Very Preterm Preeclampsia (PRESERVE-1)." American Journal of Reproductive Immunology (n.d.): 539-44. Wiley Online Library. 2013.