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Rajan Babu A, Ghazzal S, Alrowaiei AH, Johnston KJA, Alansari B. Labour epidural in a patient with neurofibromatosis type 1 or von Recklinghausen's disease: a shift in recommendations? Int J Obstet Anesth 2023; 53:103616. [PMID: 36529573 DOI: 10.1016/j.ijoa.2022.103616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 10/27/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Affiliation(s)
- A Rajan Babu
- King Hamad University Hospital, Busaiteen, Bahrain.
| | - S Ghazzal
- King Hamad University Hospital, Busaiteen, Bahrain
| | | | | | - B Alansari
- King Hamad University Hospital, Busaiteen, Bahrain
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2
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Anesthesia management in a pregnant patient with neurofibromatosis. JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.907090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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3
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Walsh E, Zhang Y, Madden H, Lehrich J, Leffert L. Pragmatic approach to neuraxial anesthesia in obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system. Reg Anesth Pain Med 2020; 46:258-267. [PMID: 33115718 DOI: 10.1136/rapm-2020-101792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/21/2020] [Accepted: 08/22/2020] [Indexed: 11/04/2022]
Abstract
Neuraxial anesthesia provides optimal labor analgesia and cesarean delivery anesthesia. Obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system present unique challenges to the anesthesiologist. Potential concerns include mechanical interference, patient injury and the need for imaging. Unfortunately, the existing literature regarding neuraxial anesthesia in these patients is largely limited to case series and rare retrospective studies. The lack of practice guidance may lead to unwarranted fear of patient harm and subsequent avoidance of neuraxial anesthesia for cesarean delivery or neuraxial analgesia for labor, with additional risks of exposure to general anesthesia. In this narrative review, we use available evidence to recommend a framework when considering neuraxial anesthesia for an obstetrical patient with neuraxial pathology.
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Affiliation(s)
- Elisa Walsh
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yi Zhang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hannah Madden
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James Lehrich
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lisa Leffert
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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4
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Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy. Reg Anesth Pain Med 2018; 43:263-309. [DOI: 10.1097/aap.0000000000000763] [Citation(s) in RCA: 442] [Impact Index Per Article: 73.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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5
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Gálvez JL, Errando CL, Serrano S, Martín-Ayuso M, Valverde-Mantecón JM. Intravenous Remifentanil Analgaesia for an Obstetric Patient with Type I Neurofibromatosis and a Factor V Leiden Mutation. Sultan Qaboos Univ Med J 2018; 17:e468-e471. [PMID: 29372092 DOI: 10.18295/squmj.2017.17.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 06/09/2017] [Accepted: 07/06/2017] [Indexed: 11/16/2022] Open
Abstract
Type I neurofibromatosis is characterised by altered skin pigmentation and the growth of benign tumours, particularly along the peripheral nerves and central nervous system. We report a 36-year-old primigravida woman in labour who was admitted to the obstetric suite of the Hospital Sant Joan de Déu, Barcelona, Spain, in 2007 with hypothyroidism, type I neurofibromatosis and a factor V Leiden mutation. Due to a lack of cranial and spinal imaging data, an epidural was not indicated; instead, continuous intravenous remifentanil analgaesia was administered. The remifentanil infusion was self-titrated by the patient using a visual analogue scale, with the dosage ranging from 0.01 to 0.25 μg/kg/minute. Due to rotational dystocia, Kjelland-type forceps were used during the delivery. After birth, the infant was found to have Apgar scores of 9 and 10, with no maternal or neonatal adverse effects observed. Although still controversial, remifentanil may be a successful alternative for analgaesia in similar cases; however, the specific risks and benefits for each patient should be considered prior to administration.
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Affiliation(s)
- José L Gálvez
- Department of Anaesthesiology, Resuscitation & Pain Therapeutics, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - Carlos L Errando
- Department of Surgical Services, Consorcio Hospital General Universitario de Valencia, Valencia, Spain.,Department of Anaesthesiology, Resuscitation & Pain Therapeutics, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Silvia Serrano
- Department of Anaesthesiology, Resuscitation & Pain Therapeutics, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Marga Martín-Ayuso
- Department of Anaesthesiology, Resuscitation & Pain Therapeutics, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - José M Valverde-Mantecón
- Department of Anaesthesiology, Resuscitation & Pain Therapeutics, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
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Galvan JM, Hofkamp MP. Usefulness of intrapartum magnetic resonance imaging for a parturient with neurofibromatosis type 1 during induction of labor for preeclampsia. Proc (Bayl Univ Med Cent) 2018; 31:92-93. [DOI: 10.1080/08998280.2017.1401837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Jacqueline M. Galvan
- Department of Anesthesiology, University of Illinois at Chicago, Chicago, Illinois
| | - Michael P. Hofkamp
- Department of Anesthesiology, Scott & White Medical Center–Temple, Temple, Texas
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7
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Puerperal ventral epidural hematoma after epidural labor analgesia. Int J Obstet Anesth 2017; 31:100-104. [PMID: 28499552 DOI: 10.1016/j.ijoa.2017.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 03/12/2017] [Accepted: 03/25/2017] [Indexed: 11/20/2022]
Abstract
Serious complications in obstetric anesthesia are a rare occurrence. High neuraxial block, respiratory arrest in labor and delivery, and an unrecognized spinal catheter are among the most frequently reported serious complications. A serious complication occurs in approximately 1:3000 obstetric patients. Neuraxial hematoma after obstetric epidural analgesia or anesthesia is extremely rare. We present a case of a puerperal spinal epidural hematoma following epidural labor analgesia. The patient presented with foot drop, which resolved after conservative treatment. We reviewed the epidemiology, clinical manifestations and treatment options for this rare complication.
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Lagerkranser M. Neuraxial blocks and spinal haematoma: Review of 166 case reports published 1994–2015. Part 1: Demographics and risk-factors. Scand J Pain 2017; 15:118-129. [DOI: 10.1016/j.sjpain.2016.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Abstract
Background
Bleeding into the vertebral canal causing a spinal haematoma (SH) is a rare but serious complication to central neuraxial blocks (CNB). Of all serious complications to CNBs such as meningitis, abscess, cardiovascular collapse, and nerve injury, neurological injury associated with SH has the worst prognosis for permanent harm. Around the turn of the millennium, the first guidelines were published that aimed to reduce the risk of this complication. These guidelines are based on known risk factors for SH, rather than evidence from randomised, controlled trials (RCTs). RCTs, and therefore meta-analysis of RCTs, are not appropriate for identifying rare events. Analysing published case reports of rare complications may at least reveal risk factors and can thereby improve management of CNBs. The aims of the present review were to analyse case reports of SH after CNBs published between 1994 and 2015, and compare these with previous reviews of case reports.
Methods
MEDLINE and EMBASE were used for identifying case reports published in English, German, or Scandinavian languages, using appropriate search terms. Reference lists were also scrutinised for case reports. Twenty different variables from each case were specifically searched for and filled out on an Excel spreadsheet, and incidences were calculated using the number of informative reports as denominator for each variable.
Results
Altogether 166 case reports on spinal haematoma after CNB published during the years between 1994 and 2015 were collected. The annual number of case reports published during this period almost trebled compared with the two preceding decades. This trend continued even after the first guidelines on safe practice of CNBs appeared around year 2000, although more cases complied with such guidelines during the second half of the observation period (2005–2015) than during the first half. Three types of risk factors dominated:(1)Patient-related risk factors such as haemostatic and spinal disorders, (2) CNB-procedure-related risks such as complicated block, (3) Drug-related risks, i.e. medication with antihaemostatic drugs.
Conclusions and implications
The annual number of published cases of spinal haematoma after central neuraxial blocks increased during the last two decades (1994–2015) compared to previous decades. Case reports on elderly women account for this increase.Antihaemostatic drugs, heparins in particular, are still major risk factors for developing post-CNB spinal bleedings. Other risk factors are haemostatic and spinal disorders and complicated blocks, especially “bloody taps”, whereas multiple attempts do not seem to increase the risk of bleeding. In a large number of cases, no risk factor was reported. Guidelines issued around the turn of the century do not seem to have affected the number of published reports. In most cases, guidelines were followed, especially during the second half of the study period. Thus, although guidelines reduce the risk of a post-CNB spinal haematoma, and should be strictly adhered to in every single case, they are no guarantee against such bleedings to occur.
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Affiliation(s)
- Michael Lagerkranser
- Section for Anaesthesiology and Intensive Care Medicine , Department of Physiology and Pharmacology , Karolinska Institutet , 171 77 Stockholm Stockholm , Sweden
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9
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Jeon DG, Song JG, Kim SK, Kim J. Epidural hematoma after thoracic epidural analgesia in a patient treated with ketorolac, mefenamic acid, and naftazone: a case report. Korean J Anesthesiol 2014; 66:240-3. [PMID: 24729848 PMCID: PMC3983422 DOI: 10.4097/kjae.2014.66.3.240] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Revised: 03/05/2013] [Accepted: 03/07/2013] [Indexed: 11/10/2022] Open
Abstract
A 26-year-old male undergoing thoracotomy and bleeding control received a preoperative thoracic epidural for postoperative analgesia. On the fifth postoperative day, paralysis of both lower limbs occurred and urgent magnetic resonance imaging showed massive anterior epidural hematoma. During laminectomy and decompression, platelet dysfunction was diagnosed and preoperative non-steroidal anti-inflammatory drugs medications were supposed to the cause of platelet dysfunction. After infusion of ten units of platelet concentrate, coagulopathy was improved. We should be more careful to drugs with antiplatelet effect when using regional analgesia.
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Affiliation(s)
- Dae Geun Jeon
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Jae Gyok Song
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Seok-Kon Kim
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Juri Kim
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
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10
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Ultrasound-guided popliteal nerve block in a patient with malignant degeneration of neurofibromatosis 1. Case Rep Anesthesiol 2012; 2012:753769. [PMID: 22649742 PMCID: PMC3357589 DOI: 10.1155/2012/753769] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Accepted: 03/13/2012] [Indexed: 12/04/2022] Open
Abstract
A 41-year-old female patient with neurofibromatosis 1 presented with new neurologic deficits secondary to malignant degeneration of a tibial lesion. Ultrasound mapping of the popliteal nerve revealed changes consistent with an intraneural neurofibroma. Successful popliteal nerve blockade was achieved under ultrasound guidance.
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11
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Bhagyalakshmi R, Koshy R. Femoral sciatic block: A safe alternative in von Recklinghausen′s disease. Indian J Anaesth 2011; 55:210-2. [PMID: 21712892 PMCID: PMC3106409 DOI: 10.4103/0019-5049.79885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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12
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Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med 2010; 35:64-101. [PMID: 20052816 DOI: 10.1097/aap.0b013e3181c15c70] [Citation(s) in RCA: 658] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The actual incidence of neurologic dysfunction resulting from hemorrhagic complications associated with neuraxial blockade is unknown. Although the incidence cited in the literature is estimated to be less than 1 in 150,000 epidural and less than 1 in 220,000 spinal anesthetics, recent epidemiologic surveys suggest that the frequency is increasing and may be as high as 1 in 3000 in some patient populations.Overall, the risk of clinically significant bleeding increase with age,associated abnormalities of the spinal cord or vertebral column, the presence of an underlying coagulopathy, difficulty during needle placement,and an indwelling neuraxial catheter during sustained anticoagulation( particularly with standard heparin or low-molecular weight heparin). The need for prompt diagnosis and intervention to optimize neurologic outcome is also consistently reported. In response to these patient safety issues, the American Society of Regional Anesthesia and Pain Medicine (ASRA) convened its Third Consensus Conference on Regional Anesthesia and Anticoagulation. Practice guidelines or recommendations summarize evidence-based reviews. However, the rarity of spinal hematoma defies a prospective randomized study, and there is no current laboratory model. As a result,the ASRA consensus statements represent the collective experience of recognized experts in the field of neuraxial anesthesia and anticoagulation. These are based on case reports, clinical series, pharmacology,hematology, and risk factors for surgical bleeding. An understanding of the complexity of this issue is essential to patient management.
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13
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Tanaka M, Balki M, McLeod A, Carvalho JC. Regional Anesthesia and Non-Preeclamptic Thrombocytopenia: Time to Re-Think the Safe Platelet Count. Braz J Anesthesiol 2009; 59:142-53. [DOI: 10.1590/s0034-70942009000200002] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2008] [Accepted: 01/05/2009] [Indexed: 11/21/2022] Open
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Ramos López L, Rama Maceiras P, Fernández Méndez M, Molíns Gauna N, Izquierdo González B. [Chance diagnosis of a spinal tumor after lumbar puncture for spinal anesthesia]. ACTA ACUST UNITED AC 2009; 55:653-5. [PMID: 19177875 DOI: 10.1016/s0034-9356(08)70686-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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15
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Abstract
The peripartum management of the anticoagulated parturient represents a significant clinical challenge to both the obstetrician and the anesthesiologist. This review discusses the causes of thrombosis in the pregnant population, the anticoagulants used for prophylaxis, and treatment of these disorders, along with recommendations for neuraxial blockade in parturients who receive peripartum anticoagulation.
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Affiliation(s)
- Sandra L Kopp
- Department of Anesthesiology, Mayo Graduate School of Medicine, Rochester, MN 55905, USA.
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16
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Affiliation(s)
- Yaakov Beilin
- Department of Anesthesiology and Obstetrics, Gynecology and Reproductive Sciences, Mount Sinai School of Medical New York, New York 10029-6579, USA.
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17
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Sakai T, Vallejo MC, Shannon KT. A parturient with neurofibromatosis type 2: anesthetic and obstetric considerations for delivery. Int J Obstet Anesth 2005; 14:332-5. [PMID: 16140520 DOI: 10.1016/j.ijoa.2005.02.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2004] [Revised: 01/11/2005] [Accepted: 02/02/2005] [Indexed: 02/05/2023]
Abstract
Neurofibromatosis type 2 is an extremely rare form of neurofibromatosis characterized by central nervous system involvement with bilateral vestibular schwannomas and spinal tumors. Anesthetic management of a parturient with neurofibromatosis type 2 has not been fully reported, and the condition is challenging to obstetric anesthesiologists due to the presence of intracranial and intraspinal canal neurofibromas. We present a case of neurofibromatosis type 2 referred for delivery. Because of central neuraxial involvement, regional anesthesia was avoided, and the patient delivered by cesarean section under general anesthesia. The importance of pre-operative diagnosis and multidisciplinary management for neurofibromatosis type 2 is emphasized and anesthetic and obstetric considerations for delivery are presented.
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Affiliation(s)
- T Sakai
- Department of Anesthesiology, Magee Women's Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
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Spiegel JE, Hapgood A, Hess PE. Epidural anesthesia in a parturient with neurofibromatosis type 2 undergoing cesarean section. Int J Obstet Anesth 2005; 14:336-9. [PMID: 16154348 DOI: 10.1016/j.ijoa.2005.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2004] [Revised: 03/01/2005] [Accepted: 04/01/2005] [Indexed: 10/25/2022]
Abstract
Neurofibromatosis type 2 (NF2) is a rare condition only recently recognized. We present a case describing successful regional analgesia in a parturient with NF2 after thorough imaging revealed no tumors within the epidural space. The presence of tumors within the spinal cord and nerve roots and their potential enlargement during pregnancy make routine neuraxial anesthesia hazardous in patients with NF2. Lumbosacral imaging before performing regional anesthesia is recommended.
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Affiliation(s)
- J E Spiegel
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, USA.
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Lighthall GK, Morgan C, Cohen SE. Correction of intraoperative coagulopathy in a patient with neurofibromatosis type I with intravenous desmopressin (DDAVP). Int J Obstet Anesth 2004; 13:174-7. [PMID: 15321397 DOI: 10.1016/j.ijoa.2004.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/01/2004] [Indexed: 11/26/2022]
Abstract
A patient with the genetic condition neurofibromatosis type I and no known coagulopathy undergoing cesarean delivery, had diffuse uterine and surgical site bleeding that was not correctable by oxytocin, methylergonovine and PGF2 alpha. Despite good uterine tone, hemorrhage continued from the uterus and the surrounding tissues, persisting even after surgical ligation of the uterine arteries. With no change in her condition, which was behaving clinically as a coagulopathy, an infusion of desmopressin acetate (DDAVP) was begun. The patient's bleeding promptly resolved shortly after infusion of this agent. A review of relevant literature suggests that platelet reactivity of patients with neurofibromatosis type 1 is attenuated in some in vitro conditions. Thus, there may be some theoretical basis for using DDAVP in patients with neurofibromatosis type 1 who have bleeding problems with no other known source, such as in the case presented here.
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Affiliation(s)
- G K Lighthall
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA.
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20
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Abramovitz S, Beilin Y. Thrombocytopenia, low molecular weight heparin, and obstetric anesthesia. ANESTHESIOLOGY CLINICS OF NORTH AMERICA 2003; 21:99-109. [PMID: 12698835 DOI: 10.1016/s0889-8537(02)00033-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The parturient with coagulation defects, whether related to thrombocytopenia or to anticoagulation therapy, presents a unique challenge to the anesthesiologist. The risk of spinal or epidural hematoma in these patients has not been quantified fully but is a factor that one must consider on a case-by-case basis in determining whether neuraxial anesthesia is appropriate for the parturient. Following the guidelines set forth in this article should help reduce the risk of spinal or epidural hematoma without sacrificing the quality of care provided to patients.
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Affiliation(s)
- Sharon Abramovitz
- Department of Anesthesiology, Weill Medical College of Cornell University, 525 East 68th Street, New York, NY 10021, USA.
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