///2019 Abstract Details
2019 Abstract Details2019-07-13T07:45:15-05:00

Epidural Anesthesia in a Parturient with Homozygous Factor XI Deficiency

Abstract Number: FCD-232
Abstract Type: Case Report Case Series

Ashley J Whisnant MD1 ; Yaakov Beilin MD2; Daniel Katz MD3

BACKGROUND:

Factor XI Deficiency is a rare autosomal inherited bleeding disorder that is common in the Ashkenazi Jewish population with a prevalence of approximately 1 in 8 for heterozygosity and 1 in 190 for a homozygous gene mutation. With increases in antenatal genetic testing, more women are presenting to the labor floor with this diagnosis. Currently there is no clear consensus on the anesthetic management of these phenotypically diverse patients.

CASE:

A 34 year old G3P1 with newly diagnosed homozygous Factor XI Deficiency presented to our labor floor at 39 weeks gestation for induction of labor. The patient was diagnosed after routine antenatal screening for IVF. She saw a hematologist and presented for an anesthesiology consult at 36 weeks gestation. The patient had a negative bleeding history despite 7 surgical challenges, including 3 prior NSVD with epidural analgesia, during which she never had increased bleeding or required a blood transfusion. Her Factor XI Levels were 6% and her aPTT was 42.2. Her ROTEM tracings were reassuring (see figure) and after discussion with the hematologist she was deemed a candidate for neuraxial anesthesia. She began oral tranexamic acid (TXA) the night prior to induction. A dural puncture epidural was performed at L4-L5 without complication. Approximately 5 hours later, the patient delivered via NSVD with a QBL of 156 and no complication from the epidural catheter. She was discharged home on postpartum day 2 and continued oral TXA for 5 days postpartum.

DISCUSSION:

Unlike other coagulation disorders, the factor level in factor XI deficiency does not correlate with the risk of bleeding. Our patient had 3 prior NSVDs and 4 prior surgeries without increased bleeding demonstrating that phenotypically her disorder is not associated with bleeding. We therefore believed it was safe to administer epidural analgesia. This case highlights the need for a collaborative approach from hematology, anesthesiology and obstetrics to safely manage these complex, phenotypically diverse patients. By taking a thorough bleeding history and performing additional coagulation profiling, e.g., ROTEM, many of these patients can be safely managed with neuraxial anesthesia.

REFERENCES:

Davies J, et al. The Management of Factor XI Deficiency in Pregnancy. Semin Thromb Hemost. 2016; 7:732-40

Shander A, et al. The Evolving Delimma of Factor XI in Pregnancy: Suggestions for Management. Anesth Analg 2018;126:2032-7



SOAP 2019