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

Abstract

Because up to 12% of obstetric patients meet criteria for the diagnosis of thrombocytopenia in pregnancy, it is not infrequent that the anesthesiologist must decide whether to proceed with a neuraxial procedure in an affected patient. Given the potential morbidity associated with general anesthesia for cesarean delivery, thoughtful consideration of which patients with thrombocytopenia are likely to have an increased risk of spinal epidural hematoma with neuraxial procedures, and when these risks outweigh the relative benefits is important to consider and to inform shared decision making with patients. Because there are substantial risks associated with withholding a neuraxial analgesic/anesthetic procedure in obstetric patients, every effort should be made to perform a bleeding history assessment and determine the thrombocytopenia etiology before admission for delivery. Whereas multiple other professional societies (obstetric, interventional pain, and hematologic) have published guidelines addressing platelet thresholds for safe neuraxial procedures, the US anesthesia professional societies have been silent on this topic. Despite a paucity of high-quality data, there are now meta-analyses that provide better estimations of risks. An interdisciplinary taskforce was convened to unite the relevant professional societies, synthesize the data, and provide a practical decision algorithm to help inform risk-benefit discussions and shared decision making with patients. Through a systematic review and modified Delphi process, the taskforce concluded that the best available evidence indicates the risk of spinal epidural hematoma associated with a platelet count ≥70,000 × 106/L is likely to be very low in obstetric patients with thrombocytopenia secondary to gestational thrombocytopenia, immune thrombocytopenia (ITP), and hypertensive disorders of pregnancy in the absence of other risk factors. Ultimately, the decision of whether to proceed with a neuraxial procedure in an obstetric patient with thrombocytopenia occurs within a clinical context. Potentially relevant factors include, but are not limited to, patient comorbidities, obstetric risk factors, airway examination, available airway equipment, risk of general anesthesia, and patient preference.

Anesthesia Considerations for Pregnant People With COVID-19 Infection

“…Second, maternal thrombocytopenia with platelet counts below the established threshold of 70,000×10 6 /L for neuraxial procedures in obstetric patients, as recommended by SOAP in a recent consensus statement, 69 were not associated with COVID-19 in the SOAP COVID-19 Registry. 52 There was 1 case with a nadir count of 40,000×10 6 /L reported in a French series of 3 thrombocytopenic parturients with mild COVID-19.…”

“…With a diagnosis of preeclampsia with or without severe features, it remains indicated to obtain a platelet count before a neuraxial procedure (neuraxial labor analgesia or spinal anesthesia for cesarean delivery), with the acceptable cutoff of 70,000×10 6 /L in the absence of any coagulopathy. 69 …”

Complex Pathology and Management in the Obstetric Patient: A Narrative Review for the Anesthesiologist

“…If thrombocytopenia is discovered during pregnancy, an assessment of bleeding history and etiology is necessary. The risk of spinal epidural hematoma associated with a platelet count ≥70,000 × 10 6 /L is likely to be very low in obstetric patients with thrombocytopenia secondary to gestational thrombocytopenia, immune thrombocytopenia (ITP), and hypertensive disorders of pregnancy in the absence of other risk factors [ 60 ]. For patients with extreme or symptomatic thrombocytopenia or other refusal of blood products, alternative analgesia should be planned.…”

Year 2021 in review - Anaesthesiology in obstetrics

“…Protože u covid pozitivních rodiček může být nezbytné podání antikoagulační terapie, je vhodné pro plánování neuroaxiální anestezie u císařského řezu mít tuto skutečnost v patrnosti a sledovat hladinu trombocytů [3]. Někteří autoři vnímají aktuální pandemii jako příležitost k vyššímu rozšíření neuroaxiální blokády [4].…”