Spontaneous subcapsular hepatic hematoma in pregnant patients

Spontaneous subcapsular hepatic hematoma (SSHH) with or without previous history of preeclampsia and/or HELLP syndrome represents a very rare pathological condition in pregnancy and postpartum, (1/45,000-1/225,000 pregnancies). Its importance for the anesthesiologist lays in its association with high morbidity and mortality for the mother (60-86%, 39%) and newborn (42%). After a high clinical suspicion, the certainty clinical diagnosis is settled by different imaging techniques. However, in most cases the diagnosis of SSHH is a casual intraoperative finding associated to a maternal or foetal compromise. Nowadays the obstetric and anaesthetic management of a SSHH is not standardized and depends on its integrity, hemodynamic stability and the gestational period when diagnosed. The possibility of an acute critic haemorrhage with necessity of massive transfusion, makes advisable to provide updated protocols for the treatment of obstetric hemorrhage, adapting them to the clinical peculiarities of these patients. After the acute phase, close attention should be kept on thromboembolic complications.

Evaluating hemostatic thresholds for neuraxial anesthesia in adults with hemorrhagic disorders and tendencies: A scoping review

Neuraxial anesthesia can be complicated by spinal or epidural hematoma and may result in permanent neurologic injury. There is a paucity of literature characterizing this serious complication in patients with congenital and acquired hemorrhagic disorders or tendencies. The objective of this scoping review was to describe the hemostatic laboratory parameters where neuraxial anesthesia has been administered with and without spinal and epidural hematoma in patients with preexisting hemorrhagic disorders and tendencies, including immune thrombocytopenia, gestational thrombocytopenia, thrombocytopenia associated with hypertensive disorders of pregnancy, platelet function disorders, von Willebrand disease, coagulation factor deficiencies, and fibrinogen disorders. A systematic search of Ovid MEDLINE, CINAHL, Embase, Scopus, and Web of Science was performed. Two authors independently reviewed all titles, abstracts, and full texts to determine study eligibility and extract data. Qualitative synthesis of 91 studies revealed significant gaps in our understanding of the risk of spinal and epidural hematoma in patients with hemorrhagic disorders and tendencies, including few studies of males and in nonobstetric settings. Most reviewed articles were small, retrospective studies at high risk for potential bias. With such low-quality data, we were unable to provide any true estimates of the risk of spinal or epidural hematoma for these patients, nor could we attribute any specific hemostatic or laboratory values to increased risk of hematoma. There is a need both for larger and more rigorously designed and reported studies on this subject and for structured, comprehensive recommendations for safe administration and removal of neuraxial anesthesia in patients with hemorrhagic disorders and tendencies.

Focused review: spinal anesthesia in severe preeclampsia

Spinal anesthesia is widely regarded as a reasonable anesthetic option for cesarean delivery in severe preeclampsia, provided there is no indwelling epidural catheter or contraindication to neuraxial anesthesia. Compared with healthy parturients, those with severe preeclampsia experience less frequent, less severe spinal-induced hypotension. In severe preeclampsia, spinal anesthesia may cause a higher incidence of hypotension than epidural anesthesia; however, this hypotension is typically easily treated and short lived and has not been linked to clinically significant differences in outcomes. In this review, we describe the advantages and limitations of spinal anesthesia in the setting of severe preeclampsia and the evidence guiding intraoperative hemodynamic management.

Anesthesia in the pregnant patient with hematologic disorders

The management of patients with hematologic disorders in pregnancy involves a multidisciplinary approach involving specialists from hematology, obstetrics, and anesthesiology. Whereas regional anesthesia has led to a decline in maternal morbidity and mortality, the presence of uncorrected coagulopathy or the use of anticoagulant or antithrombotic medications pose a special risk for the rare complication of an epidural hematoma after neuraxial anesthesia. This article briefly reviews the common principles of anesthesia for obstetric patients, provides an obstetric anesthesiologist's perspective on the implications of regional anesthesia in obstetrics, and enhances communication between the specialties.

Spinal anesthesia for lower segment Cesarean section in patients with stable eclampsia

STUDY OBJECTIVE

To report the use of spinal anesthesia in stable eclamptic patients.

DESIGN

Prospective case series.

SETTING

Emergency operating room of a metropolitan hospital.

PATIENTS

12 "stable" eclamptic parturients.

INTERVENTIONS

Subarachnoid block was instituted with hyperbaric 0.5% bupivacaine 1.7 mL with fentanyl 25 μg.

MEASUREMENTS

Intraoperative maternal hypotension, episodes of convulsion, the need to convert to general anesthesia, and Apgar scores at 1 and 5 minutes were recorded.

MAIN RESULTS

Only one of the 12 parturients had an episode of hypotension (treated by intravenous ephedrine), while no patient had a convulsion over the 48 hours after delivery. The sensory level achieved was T₅-T₆ and none of the cases was converted to general anesthesia. Median Apgar scores at 1 and 5 minutes were 8 and 9, respectively.

CONCLUSION

Spinal anesthesia avoided the known risks of general anesthesia and was not associated with any major complications.

[Anesthesia and preeclampsia]

An assessment of the patient must take place as early as possible in view of anaesthesia. It is recommended to perform a clotting screen as close as possible to the performing of an epidural anaesthesia. The use of aspirin, if indicated for the prevention of PE, does not as such, constitute a contraindication to performing an epidural anaesthesia if: With regards to the minimum platelet count, the recommended cut-off value for the performing of an epidural and spinal anaesthesia are 75 & 50 x 10(9)/l respectively, only if all of the following conditions are met: It is recommended to quickly set up an epidural anaesthesia because this will improve the blood pressure as well as the utero-placenteric haemodynamics and also because this will facilitate the management in case of a caesarean section. Whereas methylergometrine (Methergin) is contraindicated in the preeclamptic patient, it is possible to use oxytocin (Syntocinion) during and after labour. Before performing a spinal anaesthesia, it is recommended to restrain the administration of crystalloids to a maximum of 1000 ml. Also the i.v. antihypertensive treatment should be reduced or interrupted until complete establishment of the anaesthetic. In case a general anaesthesia is to be performed, an assessment of the criteria for difficult intubation should be performed immediately prior to the induction. The technique employed should be a rapid sequence induction with intubation, while preventing a surge in blood pressure induced by the tracheal intubation. Difficulties to extubate should systematically be anticipated. It is possible to perform a loco-regional anaesthesia following an eclamptic crisis if the following conditions are met: In case of overlapping seizures and/or impaired consciousness, a general anaesthesia is recommended.

Anaesthesia for the obstetric patient with (non-obstetric) systemic disease

The number of women with serious (non-obstetric) systemic diseases achieving pregnancy and requiring obstetric anaesthetic management is increasing. The conditions that are most likely to cause maternal morbidity and mortality are cardiac disease, respiratory disease, neuromuscular disease, haematological disease, connective and metabolic diseases and psychiatric conditions including substance abuse. This article discusses the anaesthetic management of the pregnant mother with such serious systemic diseases.

Anaesthetic management of a patient with thrombocytopenia

PURPOSE OF REVIEW

New insights into the role of platelets in haemostasis have enabled a better understanding of the pathophysiology of conditions associated with thrombocytopenia. The development of new drugs and the advances in blood transfusion technology have improved the clinical management of patients with thrombocytopenia. The aim of this article is to provide a concise review of major advances in the perioperative management of patients with thrombocytopenia.

RECENT FINDINGS

Thrombocytopenia is a symptom, and the underlying cause must be evaluated. Immunotherapy, corticosteroids, immunosuppressive drugs and thrombopoietic growth factors can increase the number of platelets in thrombocytopenic patients. Further, a better understanding of the pathophysiology of heparin-induced thrombocytopenia type II and the development of direct thrombin inhibitors have improved the management of these patients, especially in the perioperative period.

SUMMARY

The lack of clinical methods for predicting which type of patients with thrombocytopenia are at risk of bleeding and the effectiveness of various platelet preparations call for research initiatives to provide better guidelines for transfusion practice. Controlled clinical trials are required to evaluate strategies for the prophylactic use of platelets and thrombopoietic factors in idiopathic thrombocytopenic purpura and the use of direct thrombin inhibitors in patients with heparin-induced thrombocytopenia.

Contraindications to regional anaesthesia in obstetrics: a survey of German practice

BACKGROUND

We assessed current practice regarding indications and contraindications to regional analgesia and anaesthesia for labour and delivery in Germany.

METHODS

Questionnaires were mailed to the directors of 918 German departments of anaesthesiology.

RESULTS

A total of 397 completed replies were received representing 41.3% of all deliveries in Germany. More than half of the respondents never perform spinal or epidural anaesthesia when the platelet count falls below 65x10(9)/L. Preeclampsia, which was not graded for severity, was considered an absolute contraindication to regional block by 15% and placenta praevia by 30% of respondents. If a woman had taken aspirin three days before, the numbers of respondents considering epidural anaesthesia contraindicated (40.2%) were nearly double those considering spinal anaesthesia contraindicated (21.7%) (P<0.001). For a platelet count of 79x10(9)/L, epidural anaesthesia was thought to be contraindicated by 37% and spinal anaesthesia by 22.2% (P=0.001). In departments with <500 deliveries/year, reluctance to use regional blockade was more pronounced than in departments with >1000 deliveries/year.

CONCLUSION

Clinical practice varies considerably in Germany. Concerns regarding the use of regional blockade were more prevalent in hospitals with small delivery units. Indications and contraindications are not consistent in Germany and some recommendations or guidelines are needed.

Hemostatic Function in Healthy Pregnant and Preeclamptic Women: An Assessment Using the Platelet Function Analyzer (PFA-100??) and Thromboelastograph??

BACKGROUND

The PFA-100 is a point-of-care platelet function analyzer which measures the speed of formation of a platelet plug in vitro, expressed as closure time (CT) in seconds. This device could potentially be used to assess primary hemostasis prior to regional anesthesia. In this prospective, observational study we sought to establish 95% reference intervals for PFA-100 and Thromboelastograph (TEG) values for our normal pregnant population, before comparing the PFA and TEG in measuring platelet function in preeclamptic and healthy pregnant women at term, using confidence interval analysis and analysis of variance.

METHODS

Routine hematologic and coagulation tests were performed along with von Willebrand Factor, CT, and TEG measurements. Results are expressed as mean (sd).

RESULTS

Increased severity of preeclampsia was associated with increasing prolongation of CT, even in the presence of normal platelet counts. In severe preeclampsia, the PFA-100 CT (mean (sd): 155 (65) s) exceeded the 95% reference interval of the control group (70-139 s). In contrast, TEG maximum amplitude (MA) in severe preeclampsia (mean (sd): 71 (8) mm) remained within the 95% reference interval for MA in normal pregnancy (64-82 mm).

CONCLUSION

We conclude that impairment of primary hemostatic function with increasing severity of preeclampsia was recorded by the PFA-100 but not the TEG.

Controversies in the delivery suite: obstetrical anesthesia for the parturient with cavernous transformation of the portal vein

INTRODUCTION

Cavernous transformation of the portal vein (CTPV) is a rare disorder resulting from extrahepatic portal vein thrombosis and development of collateral venous circulation.

CASE REPORT

I herein present the first reported case of a pregnant patient with CTPV associated with persistent consumptive coagulopathy and chronic thrombocytopenia.

OUTCOME

Single-dose spinal anesthesia was safely conducted for an uneventful cesarean delivery.

Management of a parturient with paroxysmal nocturnal haemoglobinuria

We present the case of a 30-year-old parturient diagnosed in the first trimester of her first pregnancy as having paroxysmal nocturnal haemoglobinuria. Pancytopenia necessitated regular transfusion of blood products. The risks of infection, haemorrhage and thrombosis, in the presence of severe thrombocytopenia, mild neutropenia and prophylactic anticoagulation, posed management challenges. We discuss the pathophysiology of paroxysmal nocturnal haemoglobinuria and the impact of pregnancy on the disorder, particularly on maternal morbidities such as thrombosis. The issues relevant to antenatal and peripartum obstetric, haematological and anaesthetic care for vaginal delivery are considered. Severe thrombocytopenia proved a contraindication to regional techniques and she required general anaesthesia for evacuation of a retained placenta. The post-partum period was complicated by fever and a requirement for blood products. Management of these problems, of prophylactic anticoagulation and subsequent therapy, are discussed.

Anaesthetic dilemma: spinal anaesthesia in an eclamptic patient with mild thrombocytopenia and an “impossible” airway

We present our anaesthetic management of a 27-year-old woman with antepartum eclampsia, mild thrombocytopenia, difficult airway and clinical evidence of impending upper airway obstruction. She required urgent delivery by caesarean section, which was conducted uneventfully under spinal anaesthesia. We discuss the management conundrums presented by this case and why we chose spinal anaesthesia over other anaesthetic options.

Thrombocytopenia in the parturient

Thrombocytopenia in pregnant women can be associated with substantial maternal and neonatal morbidity. It may result from a range of conditions and early implementation of some specific treatment may improve both maternal and neonatal outcome. In this review we discuss the clinical features of the more common causes of thrombocytopenia associated with pregnancy, and provide an overview of the anaesthetic considerations.

Anesthetic management of a parturient with congenital cavernous transformation of the portal vein and chronic thrombocytopenia

Cavernous transformation of the portal vein is a rare disorder resulting from extrahepatic portal vein thrombosis and development of collateral venous circulation. We report a case of a pregnant patient with congenital cavernous transformation of the portal vein associated with persistent consumptive coagulopathy and chronic thrombocytopenia. Single dose spinal anesthesia was safely conducted for an uneventful cesarean delivery.

Central nerve block and coagulation: a survey of obstetric anaesthetists

We conducted a survey amongst anaesthetists in 264 obstetric units in the UK to examine their practice in relation to potential clotting abnormalities. The survey was conducted between July and November 1998 and shows a varied opinion and practice. We received a return of 226 (86%) with 64-78% of respondents willing to perform a central nerve block at a platelet count of 80 x 10(9)/L or more. Patients on aspirin alone or aspirin and heparin would be given a central nerve block by up to 96% and 43% of respondents respectively. Following administration of heparin, up to 22% of respondents would perform a central nerve block within 2 h while up to 64% would wait beyond 4 h. Eighty-five units had departmental policies on the removal of epidural catheters but only 15 differentiated between unfractionated and low molecular weight heparin.

Pregnancy complicated by severe osteogenesis imperfecta: a report of two cases

IMPLICATIONS

This case report discusses the anesthetic management of two parturients with severe osteogenesis imperfecta who presented for cesarean delivery. Although the anesthetic management for milder forms of the disease has been previously reported, anesthetic options for cases of this severity have not.