Disorders of coagulation in pregnancy Katz, D.; Beilin, Y.
British journal of anaesthesia : BJA,
December 2015, 20151201, 2015-Dec, 2015-12-00, Letnik:
115, Številka:
suppl_2
Journal Article
Recenzirano
Odprti dostop
The process of haemostasis is complex and is further complicated in the parturient because of the physiological changes of pregnancy. Understanding these changes and the impact that they have on the ...safety profile of the anaesthetic options for labour and delivery is crucial to any anaesthetist caring for the parturient. This article analyses current theories on coagulation and reviews the physiological changes to coagulation that occur during pregnancy and the best methods with which to evaluate coagulation. Finally, we examine some of the more common disorders of coagulation that occur during pregnancy, including von Willebrand disease, common factor deficiencies, platelet disorders, the parturient on anticoagulants, and the more rare acute fatty liver of pregnancy, with a focus on their implications for neuraxial anaesthesia.
•It is important to reduce or eliminate opioid use for post-cesarean delivery pain.•Many parenteral non-opioid medications can be used to treat post-cesarean pain.•Anti-inflammatory drugs and ...acetaminophen are useful in treating postoperative pain.•Steroids and lidocaine appear promising analgesics but further study is needed.
It is critical to adequately treat postoperative cesarean delivery pain. The use of parenteral or neuraxial opioids has been a mainstay, but opioids have side effects that can be troubling and the opioid crisis in the United States has highlighted the necessity to utilize analgesics other than opioids. Other analgesic options include neuraxial analgesics, nerve blocks such as the transversus abdominis plane block, and non-opioid parenteral and oral medications. The goal of this article is to review non-opioid systemic analgesic adjuncts following cesarean delivery, focusing on their efficacy and side effects as well as their impact on reduction of opioid requirements after surgery.
•Quantitative assessment of blood loss (QBL) systems are available.•Introduction of a QBL system suggested differences compared with simple estimation of blood loss.•Differences were in the timing ...and volume of peripartum blood loss.•Recognition of postpartum haemorrhage was enhanced but blood loss lower.•Differences in outcomes associated with QBL varied according to mode of delivery.
Imprecise visual estimates of blood loss contribute to morbidity from postpartum hemorrhage. We examined the impact of quantitative assessment of postpartum blood loss on clinical practice and outcomes.
An observational study comparing blood loss, management and outcomes between two historical cohorts (August 2016 to January 2017 and August 2017 to January 2018) at an academic tertiary care center. Patients in the intervention group (second period) had blood loss quantified compared with visual estimation for controls.
We included 7618 deliveries (intervention group n=3807; control group n=3811). There was an increase in the incidence of hemorrhage (blood loss >1 L) in the intervention group for both vaginal (2.2% vs 0.5%, P <0.001) and cesarean delivery (12.6% vs 6.4%, P <0.001). There was also a difference in median blood loss for vaginal (258 mL 151–384 vs 300 mL 300–350, P <0.001); and for cesarean delivery (702 mL 501–857 vs 800 mL 800–900, P <0.001). The median red blood cell units transfused was different in the intervention group having cesarean delivery (2 units 1–2 vs 2 units 2–2, P=0.043). Secondary uterotonic usage was greater in the intervention group for vaginal (22% vs 17.3%, P <0.001) but not cesarean delivery (7.0% vs 6.0%, P=0.177). Laboratory costs were different, but not the re-admission rate or length of stay.
Quantifying blood loss may result in increased vigilance for vaginal and cesarean delivery. We identified an association between quantifying blood loss and improved identification of postpartum hemorrhage, patient management steps and cost savings.
(J Clin Anesth. 2020;62:109741)Preeclampsia is a multisystem disease that affects the coagulation system and platelets of 3% to 5% of all patients, and accounts for 16% of all prenatal ...thrombocytopenia cases. Routine neuraxial analgesia/anesthesia procedures carry a risk of the patient developing a spinal epidural hematoma, which is problematic for parturients with coagulation disorders. While health administrative bodies have advised that care providers consider platelet count before neuraxial anesthesia placement in preeclamptic patients, there is currently no agreed-upon minimum platelet count considered safe for a neuraxial anesthetic procedure. Beilin and colleagues conducted this study of preeclamptic patients to measure the frequency of platelet count <100,000 mm, as well as to observe the percentage decrease in platelet count during the 72-hour period before delivery.
(Anesth Analg. 2019. doi10.1213/ANE.0000000000004155)At term, about 3% to 4% of worldwide pregnancies have a fetus in the breech presentation, a common risk factor for delivery complications. The ...current recommendation to reduce perinatal morbidity and mortality with breech presentation is to perform a cesarean delivery. An alternative is external cephalic version, in which the fetus is manually rotated into vertex position to allow for an attempted vaginal delivery. The success rate of this procedure increases via utilization of neuraxial anesthesia, which allows for the relaxation of abdominal muscles, and via tocolytic agents which provide uterine relaxation. Two examples of such tocolytic agents are nitroglycerin and terbutaline. The authors of this study hypothesized that no difference in the successful cephalic version rate would exist between nitroglycerin and terbutaline.
(Anesth Analg. 2019;129(3):e86–e88)Postpartum hemorrhage (PPH) is a life-threatening event that affects pregnant women globally. A deficiency of fibrinogen in the blood can help physicians predict ...the severity of PPH. Historically, the Clauss method has been used to measure fibrinogen levels, but this approach is more time-consuming than point-of-care (POC) thromboelastography (TEG) or thromboelastometry testing. There has not been much research focused specifically on the correlation of TEG functional fibrinogen (FLEV) to Clauss levels in obstetric patients who may have distinctive coagulation profiles compared with trauma, cardiac, or transplant patients. These investigators conducted this study to discover if the POC FLEV is consistent with the laboratory Clauss fibrinogen measurement.
(Anesth Analg. 2020;130:436–444)As births using assisted reproductive technology increase, the maternal and neonatal safety of these pregnancies continues to be of concern. There are established ...associations between assisted reproductive technology pregnancies and a number of adverse outcomes, including gestational diabetes, hypertensive disorders of pregnancy, obstetric hemorrhage, abnormal placentation, and cesarean delivery. There is a lack of studies examining the risk of intensive care unit (ICU) admission in women using assisted reproductive technology. This study compared parturients who conceived via in vitro fertilization (IVF) and those who did not in terms of etiology and course of ICU admission, particularly focusing on postpartum hemorrhage.
(J Clin Anesth. 2015;27:60–62)Although anesthesia providers will rarely care for a parturient that has undergone a Fontan procedure, improving survival rates and functional status among women ...post-Fontan mean that obstetrical care for patients with Fontan physiology will become more common. It is therefore important for anesthesiologists to understand the cardiac physiology of after Fontan repair and the impact of the physiological changes of pregnancy.This case report offers an account of the successful use of epidural anesthesia for cesarean delivery in a woman with Fontan repair.
(J Clin Anesth. 2020;61:109666)Presently, there is no agreement among experts in regards to the safe minimum threshold platelet count for lumbar neuraxial anesthetic procedures, as there are limited ...data available on neuraxial anesthetic procedures performed on thrombocytopenic patients. During cesarean deliveries, there are important maternal and fetal factors and side effects to consider when choosing to administer general anesthesia rather than neuraxial anesthesia. Because more data on spinal epidural hematoma are needed, Bauer and colleagues conducted this systematic review to assemble reported lumbar neuraxial procedures (lumbar puncture; spinal, epidural, or combined spinal-epidural analgesia/anesthesia; epidural catheter removal) from various thrombocytopenic populations to bring some clarity to the risk of spinal epidural hematoma.
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