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Use of Thromboelastography to Guide the Perioperative Management of a Parturient with Antithrombin Deficiency and Factor XI Deficiency
Abstract Number: RF3BC-259
Abstract Type: Case Report Case Series
Introduction: Deficiency in Factor XI, a plasma serine protease that contributes to thrombin generation, may result in excessive postoperative bleeding (1). Antithrombin (AT) inhibits the coagulation cascade’s serine proteases, and deficiency leads to thrombophilia (2). Thromboelastography (TEG) has been shown to be superior to routine coagulation tests (RCT) in predicting postoperative bleeding after cardiac surgery and to confer a survival advantage over RCT when guiding product transfusion in massive transfusion protocol in trauma patients (3,4). Concurrent Factor XI and AT deficiency is extremely rare. We report the use of TEG to guide management for a parturient with these conditions.
Case: A 32 year old G4P1 at 37 weeks gestation with deficiencies in AT (activity 32%) and factor XI (level 7%) presented for primary cesarean delivery (CD) due to complete placenta previa. She lost two prior pregnancies. Her third pregnancy was a term vaginal delivery. She received an epidural after normal TEG result without complications. She underwent molar extraction and tonsillectomy without excessive bleeding. Given absence of venous thromboembolism history and factor XI deficiency, antepartum anticoagulation was deferred.
Anesthetic management for her CD posed many challenges. A team approach was applied with consults by hematology and obstetric anesthesiology in her third trimester. RCT and TEG were normal at the consult. Repeat TEG on the day of surgery was also normal (Fig 1). Given her surgical history without excessive bleeding, concurrent AT deficiency was thought to limit her tendency to bleed, so FFP or factor XI concentrate was not prophylactically transfused. Due to a normal TEG and lack of bleeding history, spinal anesthetic was planned after discussion with the patient and obstetric team. Spinal placement and CD were uneventful. Postoperative neurological status was closely monitored. She was discharged home on postpartum day 4.
Discussion: While no literature exists to quantify the risk of epidural or spinal hematoma following neuraxial anesthesia in such a patient, TEG provided point of care information about coagulation status and helped to inform the choice of neuraxial or general anesthesia for CD in a patient with factor XI and AT deficiencies.
1. Clinical and Applied Thrombosis/Hemostasis. 2010;16(2):209-213.
2. Thrombosis Research. 2017;157:41-45.
3. Ann Card Anaesth. 2018;21:151-157.
4. Crit Care Clin. 2017;33(1):119-134.