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.
Abstract In the EXIT (ex utero intrapartum treatment) procedure, after uterine incision, uterine relaxation is maintained to prevent placental separation and the fetus is supported via the placenta ...until the airway is successfully established. The traditional method to maintain uterine relaxation is with the use of high-dose potent inhaled anesthetics during general anesthesia. A patient with a family history of malignant hyperthermia required an EXIT procedure. The history of malignant hyperthermia precluded the use of potent inhaled anesthetics and an alternate plan using propofol and remifentanil infusions for anesthesia and nitroglycerin 16 μg/kg/min for uterine relaxation allowed for good surgical conditions. The presence of malignant hyperthermia required an alternate plan and close collaboration in order to ensure good patient outcome.
The platelet function analyzer (PFA-100®) is a bedside test of coagulation designed to evaluate platelet function. It measures the time required for whole blood to occlude a membrane impregnated with ...either epinephrine (EPI) or adenosine 5′diphosphate (ADP). The results are reported as closure time (CT-EPI or CT-ADP) in seconds. The thromboelastogram (TEG) measures whole blood clotting and the maximum amplitude (MA) correlates with platelet count and function. We wished to establish whether there is a correlation between the CT and platelet count, between the CT and MA, and between the MA and platelet count.
Platelet count, CT, and MA were measured in blood drawn from 172 healthy term parturients using the PFA-100®.
We were unable to detect a significant correlation between the CT-EPI and platelet count (r
=
−0.1,
P
=
0.21), or the CT-ADP and platelet count (r
=
−0.02,
P
=
0.83). We also did not find a correlation between the CT-EPI and MA (r
=
−0.13,
P
=
0.12) or between the CT-ADP and MA (r
=
−0.11,
P
=
0.19). However, we found a significant correlation between platelet count and MA (r
=
0.33,
P
<
0.001).
We conclude that the CT does not correlate with the platelet count or MA in the parturient, but the TEG does. Therefore the TEG may be a better tool to evaluate coagulation in the parturient with thrombocytopenia.
Summary Posterior reversible encephalopathy syndrome is a rare complication generally associated with headache and acute changes in blood pressure. We present a case of posterior reversible ...encephalopathy syndrome where diagnosis was delayed because the patient also had preeclampsia and an inadvertent dural puncture, both associated with headache. The clinical challenge and the need for prompt diagnosis and treatment are emphasized.
Complications can occur during epidural placement for women in labor. As many as 23% of epidural anesthetics may not provide satisfactory analgesia. The cause of this may be technical. This study was ...undertaken to determine the optimal distance that a multiorifice catheter should be threaded into the epidural space to maximize analgesia and minimize complications. One hundred women in labor were enrolled in this prospective, randomized, and double-blind study. Patients were randomly assigned to have the epidural catheter threaded 3, 5, or 7 cm into the epidural space. After placement of the catheter and administration of a test dose with 3 mL of 0.25% bupivacaine, an additional 10 mL of 0.25% bupivacaine was administered in two divided doses. Fifteen minutes later, the adequacy of the analgesia was assessed by a blinded observer. We found that catheter insertion to a depth of 7 cm was associated with the highest rate of insertion complications while insertion to a depth of 5 cm was associated with the highest incidence of satisfactory analgesia. For women in labor who require continuous lumbar epidural anesthesia, we recommend threading a multiorifice epidural catheter 5 cm into the epidural space.
ABSTRACT Background An anesthesia information management system (AIMS) is most frequently used in the operating room, but not on labor and delivery (L&D). The purpose of this study is to describe the ...implementation of an AIMS on L&D and the attitudes of practitioners (anesthesiologists and nurses) toward the system. Methods The anesthesiology survey focused on satisfaction with the L&D AIMS, comparison of the L&D AIMS with a handwritten anesthesia record, and comparison of the L&D AIMS with the operating room AIMS. The nursing survey focused on nursing satisfaction with the L&D AIMS and comparison of the L&D AIMS with a handwritten anesthesia record. Results Most anesthesiologists (76%) were satisfied with the L&D AIMS and 73% would not want to revert back to the paper record. However, most anesthesiologists felt the operating room AIMS was either superior or equal to the L&D AIMS. Although few nurses (4%) preferred the anesthesiologists revert back to the handwritten record overall, the nurses were neutral in their assessment of the AIMS. Most of the criticism related to the location of the system; 56% believed it was not in a convenient location and 74% thought the AIMS equipment “got in their way”. Conclusions Overall, the anesthesiologists and nurses are satisfied with the L&D AIMS and would not want to switch back to a handwritten record. We conclude that AIMS should not be limited to the operating room setting and can successfully be used in L&D.
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