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Abnormal TEG pattern in a patient with antiphospholipid antibody syndrome (APS) undergoing cesarean delivery: does it really matter?
Abstract Number: RF3BC-261
Abstract Type: Case Report Case Series
APS is associated with prolonged aPTT despite its prothrombotic state. This laboratory abnormality is caused by the interaction of antiphospholipid antibody such as lupus anticoagulant with phospholipid which is included as a reagent in aPTT test. As TEG reagent in CK test does not contain phospholipid, we measured TEG and ROTEM, expecting that normal tracings may give us some reassurance to offer regional anesthesia for her cesarean delivery (CD). However, these tests showed grossly abnormal pattern, and we were confronted with dilemma in choosing anesthesia method for her CD.
She a 26-year-old G3P1 woman with history of SLE, APS (positive lupus anticoagulant (LA) and anticardiolipin antibody (aCL)), and s/o Sjogren syndrome, as well as asymptomatic primary biliary cirrhosis. In her previous cesarean delivery due to hypertensive disorders of pregnancy, general anesthesia was chosen because of thrombocytopenia (49K) and clinical bleeding tendency. During this pregnancy, she was placed on subcutaneous heparin 5,000u SQ BID as well as aspirin 100mg daily. At the time of anesthesia consultation at 32 weeks gestation, aPTT was prolonged to 100 seconds. We evaluated both TEG and ROTEM. The following are the TEG results with reference ranges (not for pregnancy, but by the manufacturer). CK R: 21.9 min (4.6-9.1), K: 4.0 min (0.8-2.1), Ang: 49.8 degrees (63-78), MA: 60.2 mm (52-69), LY30: 3.3% (0.0-2.6). CRT R: 1.9 (0.3-1.1), K: 1.2 (0.8-2.7), otherwise normal. CKH R: 14.7 (4.3-8.3), K: 3.3 (0.8-1.9), Ang: 53.2 (64-77), MA: 59.9 (52-69). ROTEM also showed prolonged clot formation. Her platelet count, PT, and fibrinogen level were normal. The day before elective repeat CD at 38 weeks, while aspirin had been discontinued for 2 weeks, she was found to have hematoma at SQ heparin injection site. Platelet count was decreased to 67K on the morning of CD. Considering clinical bleeding tendency, TEG abnormality, and thrombocytopenia, we opted for general anesthesia with fresh frozen plasma ready. Her CD went uneventfully with estimated blood loss of 650ml, including amniotic fluid, which was a small amount in our institution.
Even though APS is known to cause prolonged aPTT, it is occasionally associated with acquired factor II deficiency, causing LA-hypoprothrombinemia syndrome. Her TEG and ROTEM results were abnormal enough for us to suspect this syndrome. In addition, her thrombocytopenia with undetermined etiology, made us give up regional anesthesia for her CD. However, small intraoperative blood loss was puzzling. The value of point-of-care device such as TEG is still debatable as a guide in choosing anesthesia method, especially in patients with APS.