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Labor analgesia in a coagulopathic parturient
Abstract Number: T-77
Abstract Type: Case Report/Case Series
Background: Management of labor analgesia in parturients with disorders of coagulation is a challenge for anesthesiologists. Although thrombocytopenia is a relative contraindication for spinal/epidural analgesia/anesthesia, reports suggest neuraxial blockade is safe with platelet counts >70,000/microliter.(1) Alternative modalities, typically IV remifentanil, provide only modest analgesia and the latter is associated with tachyphylaxis as labor progresses.(2,3) We present a controversial approach to management of labor analgesia in a coagulopathic parturient.
Case Report: A 26-yr old P0 at 38 wks’ gestation, BMI 41kg/m2 presented for induction of labor due to increasing dyspnea. Her medical history included obstructive sleep apnea (OSA) and cryptogenic hepatic cirrhosis, with esophageal varices. Laboratory studies revealed platelet count 48,000/microliter, fibrinogen 175 mg/dL, INR 1.5, and AST/ALT 119/48 units/L. Her Model for End-Stage Liver Disease score was 13. She had 2+ pitting edema in both legs and a Mallampati 2 airway score.
Twelve hours after induction of labor, the patient complained of severe pain with uterine contractions. She was offered a remifentanil IV infusion starting at 0.05mcg/kg/hr, due to concerns for development of epidural hematoma given thrombocytopenia and coagulopathy. Because of her history of OSA, and increasing somnolence at 0.1mcg/kg/hr, the staff was reluctant to titrate upward the remifentanil infusion. An interdisciplinary discussion between obstetric anesthesiologists, hepatologists, and maternal fetal medicine specialists was held to develop a plan for delivery and pain management, given inadequate analgesia, and high risk for cesarean delivery. The hepatologists advised platelet and cryopreciptate transfusion would effectively, though transiently, increase platelet count ≥ 70,000/microliter and coagulation factors to within the normal range. Pooled platelets 1unit and cryoprecipitate 1unit were transfused immediately prior to uneventful combined spinal epidural placement and patient controlled epidural analgesia. Satisfactory analgesia was achieved. Vacuum assisted vaginal delivery occurred 18hrs later. The epidural catheter was removed 2hrs postpartum, after repeat transfusion with platelets and cryoprecipitate. She was monitored for 24hrs postpartum in a high-risk unit, with hourly neurologic checks. Her sensation and motor strength returned to baseline within 12hrs.
Discussion: Transfusion of coagulation factors to facilitate neuraxial analgesia placement is controversial. After interdisciplinary consultation, we concluded that the benefits of superior labor analgesia and avoidance of respiratory depression with neuraxial blockade outweighed the limited risks associated with blood product transfusion, and poor maternal satisfaction from suboptimal analgesia with IV remifentanil.
1. Anesth Analg 1997; 85: 385-8.
2. Int J Obstet Anesth. 2016;25:66-74.
3. Anesth Analg. 1998;86:1307-11.