Epidural Analgesia and Anesthesia in a Parturient with Factor V Deficiency: A Case Report
Abstract Number: SUN--28
Abstract Type: Case Report/Case Series
Introduction: Factor V deficiency, also called parahemophilia, is a rare coagulopathy that poses an anesthetic challenge. We discuss the peripartum management of a parturient with Factor V deficiency.
Case Report: A 27-year-old G2P0100 presented for anesthesia consultation at 31 weeks and 6 days in the setting of congenital Factor V deficiency. She had no history of severe bleeding and Factor V activity level was 34%. Hematology recommended a Factor V activity level of 50%, the lower limit of “normal”, prior to neuraxial technique placement.
At 38 weeks and 6 days, our parturient presented for a planned induction of labor. After transfusing five units of fresh frozen plasma (FFP), Factor V activity reached 55% and a lumbar epidural catheter was placed. After 24 hours, her epidural catheter failed. Factor V activity was 43%, so another unit of FFP was given prior to catheter replacement.
On day four after induction of labor, the decision was made to perform cesarean delivery due to arrest of cervical dilation at 5cm. Factor V activity was 36% but FFP was not administered because she complained of shortness of breath which was concerning for volume overload. The patient delivered a healthy girl under epidural anesthesia and estimated blood loss was 700mL.
On the first postoperative day, Factor V activity again dropped to 34%. Platelets were used as a lower-volume alternative to FFP but failed to increase Factor V activity level. FFP was then transfused and the epidural catheter removed without any neurological sequelae.
Discussion: There are no guidelines to determine the safety of placing a neuraxial technique in Factor V deficiency. The only available case series of 5 parturients suggests that it may be safe if Factor V activity is ≥60%. Factor V, which has a half-life of 12-36 hours, is not commercially available as a concentrate; it is primarily replaced by transfusing FFP. Alternatives include platelets, recombinant Factor VII concentrate, anti-fibrinolytics and exchange transfusion. Transfusions carry risks of hemolysis, TRALI, TACO, anaphylaxis and infection.
In a previous case report, neuraxial analgesia was not offered when Factor V activity was 4%, which was associated with severe bleeding symptoms. Certainly, we would not place a neuraxial technique in these settings either. However, that our parturient achieved adequate postpartum hemostasis despite Factor V activity in the 30% range suggests that repeated FFP transfusions might have exposed her to unnecessary risk with no benefit.
The important teaching point from our case is that the trend in Factor V activity levels combined with clinical presentation, rather than a single snapshot value, should be used to determine the safety of placing a neuraxial technique in the parturient with Factor V deficiency.
1. Le Gouez et al. IJOA 2010
2. Huang and Koerper. Haemophilia 2008
3. Vaida et al. A&A Case Reports 2013