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Successful Labor Epidural In A Patient With Esophageal Varices, Pancytopenia, Sarcoidosis, and Combined Variable Immunodeficiency
Abstract Number: T2D-3
Abstract Type: Case Report/Case Series
Due to the friability of overdistended esophageal veins, patients with esophageal varices are at risk for hemorrhage. Patients with esophageal varices require careful, and meticulous planning to reduce the risk of hemorrhage during the peripartum period. Furthermore, the goal of providing safe neuraxial anesthesia in a patient with pancytopenia poses an additional challenge to the anesthesia team.
A 26 year old G1 with a history of esophageal varices, sarcoidosis, and combined variable immunodeficiency (CVID) complicated by pancytopenia was referred to a team of maternal fetal medicine specialists (MFM), hematologists, and obstetric anesthesiologists for delivery planning. Her antepartum lab work was significant for thrombocytopenia, with a baseline platelet count of 50,000. An upper GI endoscopy revealed 2 columns of grade II varices. In conjunction with the MFM specialists, it was agreed that a vaginal delivery with limited second stage of labor, combined with neuraxial analgesia, would be attempted if her thrombocytopenia improved. Her second stage of labor would be augmented with the use of forceps to limit the amount of valsalva and concomitant risk of varix rupture. Upon arrival for induction, her labs revealed improvement of her thrombocytopenia, with a current platelet count of 112x103. The patient was positioned, prepped sterilely, and an epidural was performed at L3-4. 5ml of bupivicaine 0.25%, and 5ml of lidocaine 1% was bolused, followed by a continuous epidural infusion of fentanyl 2 mcg/mL-ropivacaine 0.1% at 10ml/hr. Eight hours after epidural placement, an instrumented vaginal forceps delivery was made. APGAR scores were 8 and 9 at 1 and 5 minutes, respectively. A post delivery CBC revealed a platelet level of 79,000. The epidural catheter was removed safely, and the patient was discharged on day 2 following delivery without complication.
Delivery planning for this patient was multi-factorial and requires a team effort to anticipate potential risks during labor and delivery. A priority was to minimize pushing in the second stage labor, to reduce the amount of intraabdominal pressure and limit the risk of catastrophic hemorrhage. Her platelet level was also a significant concern, since neuraxial analgesia was planned. The exact level of platelets that are acceptable to safely place an epidural is highly controversial. Lee et al noted the risk of epidural hematoma associated with neuraxial techniques in parturients at a platelet count less than 70,000. In our patient her platelet count had significantly risen since her antepartum workup, emphasizing the need to analyze the trend of platelet counts. This case is an excellent example of anesthetic management in a patient with multiple co-morbities which produced concerns regarding the safe use of neuraxial labor analgesia.
1. Linden O. Lee, Anesthesiology 2017;126(6):1053-1063
2. Bernstein J, Anesthesia & Analgesia. 2016;123:165–7