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///2017 Abstract Details
2017 Abstract Details2019-08-02T15:54:53-05:00

ANESTHETIC MANAGEMENT FOR A CESAREAN SECTION IN A PARTURIENT WITH UNSPECIFIED INHERITED BLEEDING DISORDER

Abstract Number: SAT-59
Abstract Type: Case Report/Case Series

Li Li M.D., Ph.D.1 ; Chau X Doan M.D.2; Hani Y El-Omrani M.D.3; Laurent A Bollag M.D.4

Introduction: Neuraxial anesthesia, as the standard of care for Cesarean deliveries (CD), is associated with decreased blood loss[1]. However, parturients with inherited bleeding disorders are at an increased risk for epidural hematomas. A small retrospective study[2] has shown that parturients with known factor deficiencies can safely undergo neuraxial anesthesia once the specific factors are replenished. We present the anesthetic management for a CD in a patient with an unspecified inherited bleeding disorder.

Case Details: A 39-year-old G6P3 95 kg woman at 37 6/7 weeks gestational age with an unspecified inherited bleeding disorder presented for a repeat CD. She reported easy bruising, frequent gum bleeds, and heavy menses as a teenager. She also had persistent menorrhagia after her first two CD, an intra-abdominal hemorrhage after her third CD, and a compartment syndrome from a hemorrhage after an ankle surgery. Additionally, her mother had heavy menses, her grandmother died from a postpartum hemorrhage, and her three children showed petechiae after coughing or crying. An extensive hematological workup, including platelet function tests, a von Willebrand panel, and several other factor levels, did not yield any abnormal laboratory findings.

On the day of her CD, the patient received 2 units of fresh frozen plasma, 10 units of cryoprecipitates, and 2 units of platelets per hematology recommendation, before the placement of her routine spinal anesthetic. Immediately after delivery of a healthy infant, aminocaproic acid was given. Uterine tone remained poor after routine oxytocin administration, but improved with methylergonovine and misoprostol. Blood loss was an estimated 1.5 liters; and no additional blood products were given intraoperatively. Postpartum, the patient continued her fibrinolysis inhibitors, and received 2 units of platelets prophylactically. Her recovery was uneventful.

Discussion: This patient had a considerably increased risk of peripartum bleeding due to an unspecified inherited bleeding disorder. All her previous surgeries, including the three CD, were complicated by hemorrhage. Despite the lack of a specific diagnosis, the hematology consult provided detailed recommendations for blood product administration, enabling a safe spinal anesthetic followed by CD. Fibrinolysis inhibitors were started after delivery to further reduce bleeding. A spinal anesthesia was preferred, despite being the fourth repeat CD, over a combined spinal epidural to decrease the risk of an epidural hematoma. Communication between obstetric and anesthesia teams was crucial to expedite the start of surgery after the spinal placement and to aim for its timely completion.

In summary, the careful planning among obstetrics, anesthesia, and hematology helped achieve an uneventful CD in this patient with an extremely high bleeding risk.

References

[1]Guay J. (2006) J Clin Anesth. 18(2):124-8.

[2]Chi C et al. (2009) Thromb Haemost. 101(6):1104-11.

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