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Neuraxial Anesthesia in Obstetric Patients Receiving Thromboprophylaxis with Unfractionated or Low Molecular Weight Heparin: a Systematic Review of Spinal Epidural Hematoma
Abstract Number: F-11
Abstract Type: Meta Analysis/Review of the Literature
Venous thromboembolism (VTE) is a major source of maternal morbidity and mortality, with an incidence of 29.8/100,000 vaginal delivery hospitalizations and a 2-fold increased VTE risk with cesarean delivery.(1)Revised national guidelines stipulate that mechanical or pharmacological prophylaxis be used for most women after cesarean and for those at risk for ante-or postpartum VTE. In light of these practice changes, examining the literature to determine the incidence of spinal epidural hematomas (SEH) among anticoagulated women after neuraxial block is timely and topical. Our primary aim was to identify SEH associated with neuraxial anesthesia in obstetric patients with unfractionated or low molecular weight heparin thromboprophylaxis. Our secondary aim was to identify SEH in obstetric patients with thromboprophylaxis and neuraxial anesthesia without the ASRA recommended time interval between dose and neuraxial procedure.
We conducted a systematic review of published English language studies (1952- 2016) and of the Anesthesia Closed Claims Project Database (1990-2013) to identify relevant cases. Ten of 736 publications met inclusion criteria and were combined with the 5 SEH cases within 546 obstetric anesthesia Closed Claims reviews.
Results: There was no report of SEH associated with neuraxial anesthesia and thromboprophylaxis in obstetric patients. We identified 2 cases of SEH in postpartum women with neuraxial anesthesia unrelated to their thromboprophylaxis (Table). In addition, of 296 obstetric cases reported in the 10 relevant publications, 80 parturients received their neuraxial procedure before the ASRA recommended time interval since last heparin dose and did not develop a SEH.
It is encouraging that this broad systematic review did not identify a single case of SEH after neuraxial anesthesia among obstetric patients receiving thromboprophylaxis. Analysis of large scale registries with additional clinical and pharmacological data is needed to assess the impact of recent national VTE prophylaxis guidelines on SEH incidence in the obstetric population. In the interim, optimal care of obstetric patients will depend on multidisciplinary planning of anticoagulation dosing to facilitate neuraxial anesthesia, and thoughtful weighing of the relative risks and benefits of providing versus withholding neuraxial in favor of general anesthesia or non-neuraxial labor analgesic techniques.