• About Us
    • Contact Us
    • Login
    • ObGFirst
  • COVID-19
  • Alerts
  • OB
  • 2T US Atlas
  • The Genome
  • GYN
    • GYN
    • Sexual Health
  • Primary Care
  • Your Practice
  • #GrandRounds
  • My Bookshelf
  • Now@ObG
  • Media
About Us Contact Us Login ObGFirst
  • COVID-19
  • Alerts
  • OB
  • 2T US Atlas
  • The Genome
  • GYN
    • 0 CME Hours
    • GYN
    • Sexual Health
  • Primary Care
  • Your Practice
  • #GrandRounds
  • My Bookshelf
  • Now@ObG
  • Media
Alerts

Consensus Guideline: Epidural and Spinal Anesthesia in the Setting of Thrombocytopenia

image_pdfFavoriteLoadingFavorite

SUMMARY:

The Society for Obstetric Anesthesia and Perinatology (SOAP) commissioned a consensus document on the topic of  neuraxial procedures in the context of thrombocytopenia. The following professional bodies were included: American Society of Regional Anesthesia and Pain Medicine (ASRA), ACOG, SMFM, and the American Society for Hematology (ASH). The panel was convened to address an ongoing issue where obstetric patients with thrombocytopenia are often denied neuraxial anesthesia due to risk of spinal epidural hematoma. However, there are significant maternal and fetal risks associated with general anesthesia during pregnancy.

Definition and Background:

  • Thrombocytopenia  in pregnancy
    • Defined during pregnancy as a platelet count <150,000 x 106/L
  • Occurs in 7% to 12% of women
  • Most common diagnoses include
    • Gestational thrombocytopenia
    • Immune thrombocytopenia
    • Thrombocytopenia associated with hypertensive disease
  • Additional causes: Acute fatty liver of pregnancy | Thrombotic thrombocytopenic purpura | Inherited thrombocytopenia | Sepsis-induced thrombocytopenia

Note: For more information on thrombocytopenia in pregnancy including etiologies and management, see ‘Related ObG Topics’ below

Anesthesia Risks

Neuraxial Anesthesia: Thrombocytopenia-Related Spinal Henatoma

  • Spinal hematoma is the neuraxial anesthesia complication that is associated with the highest potential morbidity
  • Incidence
    • General obstetric population: 1:200,000 to 250,000
    • Incidence based on platelet count
      • 70K to 100K 106/L: 0.2%
      • 50K to 69K 106/L: 3%
      • <50K 106/L: 11% | Most spinal epidural hematomas occur in this range
  • Symptoms
    • Lower extremity motor deficit | Back pain | Lower extremities pain and paresthesia | Urinary/bowel dysfunction
    • 95% present symptoms within 48 hours of procedure
  • Management
    • Prompt imaging and neurosurgical consultation are critical
    • Treatment: Decompressive laminectomy within 8 hours of symptom onset

Risks Associated with General Anesthesia

  • Maternal
    • Severe adverse events related to induction | Failed tracheal intubation | Severe hypertensive response to tracheal intubation | Uterine atony | Inability to provide neuraxial opioids for pain control
  • Fetal:
    • Respiratory depression | Apgar < 7 at 5 minutes | Limitation on immediate breastfeeding

Laboratory Considerations

  • CBC
    • Absolute platelet count: +/- 3% coefficient of variation
    • Rarely: Low platelet counts due to clumping induced by EDTA | Collect in a tube with other anticoagulant or count manually
  • PTT, PT
    • Unless coagulation defect is known or suspected, no utility in predicting bleeding risk in pregnant women with thrombocytopenia
  • Thromboelastography (TED) and rotational thromboelastometry (ROTEM)
    • Dynamic point of care tests
    • Evaluate properties of blood clots subjected to rotation
    • Insufficient evidence to recommend routine use to determine safety of neuraxial anesthesia in obstetric patients with thrombocytopenia
  • Platelet function analyzer (PFA-100)
    • Evaluates platelet function by stimulating in-vivo platelet plug formation
    • Insufficient evidence to recommend routine use to determine safety of neuraxial anesthesia in obstetric patients with thrombocytopenia

Platelet Transfusion Prior to Neuraxial Procedure

  • Risks of platelet transfusion
    • Transfusion reaction | Circulatory overload | Acute lung injury
  • Expected increase: 30K to 50K 106/L after a pheresis-derived bag of platelets
    • Less effective in preeclampsia or consumption disorders
  • Platelet transfusions are recommended for
    • Life-threatening hemorrhage
    • In preparation for urgent surgery
  • Lack of evidence regarding efficacy: A Cochrane review assessed the benefit of platelet transfusion prior to neuraxial anesthesia and concluded that

We found no evidence from RCTs or non‐randomised studies on which to base an assessment of the correct platelet transfusion threshold prior to insertion of a lumbar puncture needle or epidural catheter

RECOMMENDATIONS: 

WITH Known Etiology of Thrombocytopenia (e.g., Gestational Thrombocytopenia, Immune Thrombocytopenia or Hypertensive Disease of Pregnancy)

  • Concern for hemostasis disorder or DIC: “Reasonable to avoid neuraxial procedures”
  • Platelet count ≥70K 106/L: “Reasonable to proceed with neuraxial procedure”
  • Platelets count between 50K and 70K 106/L: “Competing risk/benefits may justify proceeding with neuraxial procedure” | Will be dependent on clinical setting
  • Platelets count <50K 106/L: “Reasonable to avoid neuraxial procedure”

WITHOUT Known Etiology of Thrombocytopenia 

  • Concern for hemostasis disorder or DIC: “Reasonable to avoid neuraxial procedures”
  • Platelet count ≥70K 106/L without history of or current bleeding: “Reasonable to proceed with neuraxial procedure”
  • Platelets count <70K 106/L: “Additional (hematologic) work-up may be beneficial prior to proceeding with neuraxial procedure”

Aspirin Therapy in Women with Thrombocytopenia

  • There is “insufficient evidence” regarding neuraxial procedures in pregnant and postpartum women with thrombocytopenia who are taking aspirin
  • While the 1/2 life of aspirin is only 20 minutes, the lifetime of a platelet can be up to 10 days | However, hemostasis can be achieved with only 20% normal platelet COX activity
  • Due to limited data

…clinicians and patients should engage in shared decision-making about the perceived competing risks/benefits of proceeding with or withholding neuraxial anesthesia in cases of severe thrombocytopenia and concurrent aspirin use

Frequency of Lab Testing with Preeclampsia

  • Limited evidence for frequency of testing in women with thrombocytopenia and preeclampsia
  • However, in the presence of HELLP, the panel recommends that “it may be reasonable to verify platelet count within 6 hours of the planned neuraxial procedure”

Learn More – Primary Sources

The Society for Obstetric Anesthesia and Perinatology Interdisciplinary Consensus Statement on Neuraxial Procedures in Obstetric Patients with Thrombocytopenia

SOAP Thrombocytopenia Consensus Statement FINAL

Cochrane Review: Use of platelet transfusions prior to lumbar punctures or epidural anaesthesia for the prevention of complications in people with thrombocytopenia

Now You Can Get ObG Clinical Research Summaries Direct to Your Phone, with ObGFirst

ObGFirst® – Try It Free! »

image_pdfFavoriteLoadingFavorite
< Previous
All Alerts Posts

Related ObG Topics:

Gestational Thrombocytopenia – a Diagnosis of Exclusion

Sections

  • COVID-19
  • Alerts
  • OB
  • GYN
    • GYN
    • Sexual Health
  • 2T US Atlas
  • The Genome
  • Primary Care
  • Your Practice
  • #Grand Rounds
  • My Bookshelf
  • Now@ObG
  • Media

ObG Library

  • Hysteroscopy
  • Fertility
  • Site Map/
  • © ObG Project/
  • Terms and Conditions/
  • Privacy/
  • Contact Us/
© ObG Project
SSL Certificate


  • Already an ObGFirst Member?
    Welcome back

    Log In

    Want to sign up?
    Get guideline notifications
    CME Included

    Sign Up

Get Guideline Alerts Direct to Your Phone
Try ObGFirst Free!

Sign In

Lost your password?

Sign Up for ObGFirst and Stay Ahead

  • - Professional guideline notifications
  • - Daily summary of a clinically relevant
    research paper
  • - Includes 1 hour of CME every month

ObGFirst Free Trial

Already a Member of ObGFirst®?

Please log in to ObGFirst to access the 2T US Atlas

Password Trouble?

Not an ObGFirst® Member Yet?

  • - Access 2T US Atlas
  • - Guideline notifications
  • - Daily research paper summaries
  • - And lots more!
ObGFirst Free Trial

Media - Internet

Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

Jointly provided by

NOT ENOUGH CME HOURS

It appears you don't have enough CME Hours to take this Post-Test. Feel free to buy additional CME hours or upgrade your current CME subscription plan

Subscribe

JOIN OBGFIRST AND GET CME/CE CREDITS

One of the benefits of an ObGFirst subscription is the ability to earn CME/CE credits from the ObG entries you read. Tap the button to learn more about ObGFirst

Learn More
Leaving ObG Website

You are now leaving the ObG website and on your way to PRIORITY at UCSF, an independent website. Therefore, we are not responsible for the content or availability of this site