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Severe Preeclampsia, Platelet Count 40,000, and Spinal Anesthesia for Cesarean Delivery: Navigating Uncertainty at the Intersection of Patient Autonomy and Non-Maleficence
Abstract Number: SU-28
Abstract Type: Case Report/Case Series
A 28-year-old G2P1 at 32 weeks EGA, 73kg, 5’3”, with history of term vaginal delivery complicated by postpartum preeclampsia 2 yrs prior, presented with nausea, right upper abdominal pain, headache, platelet count of 62,000, BP 188/108. Betamethasone was administered and magnesium therapy was started. Other findings: PT 10.6 sec, INR 0.95, trace urine protein, Cr 0.6, Hct 34. She was transferred to our facility, where BP was 163/82, HR 116, Plt 40,000, PT 12.9 (INR 1.0), Fibrinogen 548, Hct 35, LDH 507, AST 195, UA 5.1, Cr 0.56. The patient was scheduled for CD. Skin exam revealed no petichiae. A thromboelastogram (TEG) was normal. She strongly desired to be awake during childbirth, and demonstrated sound decision-making capacity in the detailed, candid discussion regarding anesthetic risks and alternatives. She and the anesthesiologist negotiated the plan: the most experienced proceduralist would make a single attempt to administer spinal anesthesia. If procedure failure, general anesthesia (GA) would be administered. Meticulous neurological surveillance would follow postop. Spinal anesthesia (1.8 mL hyperbaric bupivacaine, 0.2mg morphine sulfate) provided satisfactory anesthesia. CD was performed uneventfully. Uterotonics (carboporst 0.25 mg IM x 2; misoprostol 0.8 mg PR) were given prophylactically, and platelets were transfused (after skin incision, obstetrician requested). Recovery was uneventful.
Besides the perennial question regarding thrombocytopenia and neuraxial anesthesia (i.e., “How low is too low?”), this case exemplifies clinical situations of great uncertainty, which threaten to pit patient autonomy against non-maleficence.1 Some might refuse to offer neuraxial anesthesia outright, based solely on the high-stakes, yet unquantifiable risk of epidural hematoma. But, this stance fails to consider strong patient preferences (e.g. being awake for delivery), the real uncertainties regarding risk (denial is a well described response to uncertainty, with consequences2), findings that likely mitigate risk (absence of petechiae, normal TEG, low weight/BMI), and the risks of GA in a thrombocytopenic preeclamptic patient. This stance may also inhibit creative management ideas designed to mitigate risk and facilitate early detection of the complication (e.g. single pass, experienced proceduralist, frequent neuro checks, patient/staff participation in neurologic surveillance). Finally, refusal to consider spinal anesthesia ignores the obligation to fully respect patient autonomy. Instead, acknowledging uncertainty allowed for a shared/informed decision-making process3 that included both patient goals and a comprehensive appraisal of risks. This yielded a favorable collaborative decision between the patient and physician while upholding both of the ethical principles of non-maleficence and patient autonomy.
1. Pellegrino E. J Contemp Health Law Policy 1994;10:47
2. Hall K. Med Educ 2002;36:216
3. Mcnutt R. JAMA 2004;292:2516