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Neuraxial Anesthesia for Cesarean Delivery in a Patient with Acquired Hypofibrinogenemia
Abstract Number: FCD-288
Abstract Type: Case Report Case Series
Introduction: Rotational thromboelastometry (ROTEM) can help diagnose, and guide resuscitation of, obstetric coagulopathy. Unlike for Prothrombin time (PT), Partial thromboplastin time (PTT), and platelets, there are few guidelines regarding fibrinogen level and safety of neuraxial anesthesia. We present a case in which ROTEM and fibrinogen concentrate helped guide anesthetic management of cesarean delivery (CD) in a patient with acquired hypofibrinogenemia due to placental abruption.
Case: A 28 year-old woman, gravida 4, para 3, at 30 weeks gestation with dichorioinic-diamniotic twins presented clinically with placental abruption: painful contractions and vaginal bleeding. She had a history of three prior uncomplicated CDs. Her contractions and bleeding stopped soon after admission. Laboratory analyses over the course of her admission were significant only for a decreasing serum fibrinogen level from 306 to 168 mg/dL. She had a consistently normal PT of ~14 s, PTT of ~26 s, and Platelet count of ~150 x 10^9/mL (Figure 1). She was diagnosed with an atypical coagulopathy characterized by hypofibrinogenemia that was thought to be on the spectrum of disseminated intravascular coagulation due to placental abruption.
On hospital day two the patient again started having painful contractions and cervical dilation. She was taken to the operating room for urgent CD. Due to her decreasing fibrinogen level, concern for epidural hematoma from neuraxial anesthesia was acknowledged; general anesthesia was considered. However, ROTEM analysis demonstrated a coagulation profile within normal limits, with a FIBTEM maximal clot firmness of 12 mm (normal 7-24 mm, Figure 2). With these data, combined with the availability of fibrinogen concentrate, the benefits of spinal anesthesia were thought to outweigh the risk of epidural hematoma.
After central access and radial artery access were obtained, the patient received a single shot spinal anesthetic as fibrinogen concentrate was administered. The surgery was complicated by post-partum hemorrhage due to atony that was treated with oxytocin, methylergonovine, misoprostol, tranexamic acid, fibrinogen concentrate, and red blood cell and fresh frozen plasma transfusion. The patient’s recovery was uneventful and she demonstrated no signs and symptoms of epidural hematoma.
Conclusion: The availability of ROTEM and fibrinogen concentrate may help guide anesthetic planning in patients with acquire hypofibrinogenemia.