Epidural and spinal anaesthesia in patients receiving anticoagulant therapy

Epidural hematoma occurred by massive bleeding intraoperatively in cesarean section after combined spinal epidural anesthesia -A case report-

We describe a case of acute lumbar epidural hematoma at the L2-3 level complicated by paraplegia, which occurred after coagulation disorder because of massive bleeding intraoperatively in cesarean section. The preoperative coagulation laboratory finding was in normal range and so we tried combined spinal epidural anesthesia. Uterine atony occurred in the operation, and there was persistant bleeding during and after the operation. After the operation, she complained of paresthesia on her both legs and was diagnosed with epidural hematoma (EDH) by radiologic examination. Emergency laminectomy on lumbar spine was carried out for hematoma evacuation and decompression of the epidural space at once. In our experience, massive bleeding during surgery may potentially increase the risk of EDH postoperatively.

Peripartum prophylaxis of thrombo-embolism

It is important to continue or introduce prophylaxis of thrombo-embolism before elective delivery or during labour if the incidence of post partum thrombo-embolism is to be reduced. Women with previous thrombo-embolism, genetic or acquired thrombophilia should receive intrapartum and post partum prophylaxis for at least six weeks. Those having operative delivery may require prophylaxis for a shorter period if there are no other risk factors. Subcutaneous unfractionated or low molecular weight heparins are the anticoagulants of choice. Available evidence shows that the use of prophylactic heparin during the course of epidural or spinal anaesthesia does not increase the risk of local haematoma although this remains an actively controversial area. To reduce the risk of osteopenia associated with long-term therapy and relieve the women of the onus of self-administered injections, heparin may be replaced by warfarin post-partum even if the mother is breastfeeding but warfarin dosage, unlike heparin, will require careful monitoring.