Safe epidural analgesia in thirty parturients with platelet counts between 69,000 and 98,000 mm(-3)

Gestational Thrombocytopenia: A Review on Recent Updates

Thrombocytopenia is a condition in which the blood platelet count is low. It is well established that the mild thrombocytopenia frequency is higher in normal pregnancy. This type of thrombocytopenia was named pregnancy-induced thrombocytopenia. However, recently, it has been widely known as gestational thrombocytopenia (GT). The rate is higher in women with a prior GT history and multiple pregnancies. However, it appears that GT is a physiological response to the pregnancy; placenta's peculiar structure and its unique blood flow pattern play major roles in GT development. There are no specific, precise, or known underlying pathophysiological mechanisms of GT, and no new specific management strategies are published yet. Therefore, we decided to do a non-systematic review of any recent updates that had been published in PubMed, EMBASE, and Web of Science about the pathophysiology of GT, its treatment, and other related topics.

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.

Use of platelet transfusions prior to lumbar punctures or epidural anaesthesia for the prevention of complications in people with thrombocytopenia

BACKGROUND

People with a low platelet count (thrombocytopenia) often require lumbar punctures or an epidural anaesthetic. Lumbar punctures can be diagnostic (haematological malignancies, subarachnoid haematoma, meningitis) or therapeutic (spinal anaesthetic, administration of chemotherapy). Epidural catheters are placed for administration of epidural anaesthetic. Current practice in many countries is to correct thrombocytopenia with platelet transfusions prior to lumbar punctures and epidural anaesthesia, in order to mitigate the risk of serious procedure-related bleeding. However, the platelet count threshold recommended prior to these procedures varies significantly from country to country. This indicates significant uncertainty among clinicians regarding the correct management of these patients. The risk of bleeding appears to be low, but if bleeding occurs it can be very serious (spinal haematoma). Consequently, people may be exposed to the risks of a platelet transfusion without any obvious clinical benefit.This is an update of a Cochrane Review first published in 2016.

OBJECTIVES

To assess the effects of different platelet transfusion thresholds prior to a lumbar puncture or epidural anaesthesia in people with thrombocytopenia (low platelet count).

SEARCH METHODS

We searched for randomised controlled trials (RCTs), non-randomised controlled trials (nRCTs), controlled before-after studies (CBAs), interrupted time series studies (ITSs), and cohort studies in CENTRAL (the Cochrane Library 2018, Issue 1), MEDLINE (from 1946), Embase (from 1974), the Transfusion Evidence Library (from 1950), and ongoing trial databases to 13 February 2018.

SELECTION CRITERIA

We included RCTs, nRCTs, CBAs, ITSs, and cohort studies involving transfusions of platelet concentrates, prepared either from individual units of whole blood or by apheresis, and given to prevent bleeding in people of any age with thrombocytopenia requiring insertion of a lumbar puncture needle or epidural catheter.The original review only included RCTs.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane for including RCTs, nRCTs, CBAs, and ITSs. Two review authors independently assessed studies for eligibility and risk of bias and extracted data. Results were only expressed narratively.

MAIN RESULTS

We identified no completed or ongoing RCTs, nRCTs, CBAs, or ITSs. No studies included people undergoing an epidural procedure. No studies compared different platelet count thresholds prior to a procedure.In this update we identified three retrospective cohort studies that contained participants who did and did not receive platelet transfusions prior to lumbar puncture procedures. All three studies were carried out in people with cancer, most of whom had a haematological malignancy. Two studies were in children, and one was in adults.The number of participants receiving platelet transfusions prior to the lumbar puncture procedures was not reported in one study. We therefore only summarised in a narrative form the relevant outcomes from two studies (150 participants; 129 children and 21 adults), in which the number of participants who received the transfusion was given.We judged the overall risk of bias for all reported outcomes for both studies as 'serious' based on the ROBINS-I tool.No procedure-related major bleeding occurred in the two studies that reported this outcome (2 studies, 150 participants, no cases, very low-quality evidence).There was no evidence of a difference in the risk of minor bleeding (traumatic tap) in participants who received platelet transfusions before a lumbar puncture and those who did not receive a platelet transfusion before the procedure (2 studies, 150 participants, very low-quality evidence). One of the 14 adults who received a platelet transfusion experienced minor bleeding (traumatic tap; defined as at least 500 x 10⁶/L red blood cells in the cerebrospinal fluid); none of the seven adults who did not receive a platelet transfusion experienced this event. Ten children experienced minor bleeding (traumatic taps; defined as at least 100 x 10⁶/L red blood cells in the cerebrospinal fluid), six out of the 57 children who received a platelet transfusion and four out of the 72 children who did not receive a platelet transfusion.No serious adverse events occurred in the one study that reported this outcome (1 study, 21 participants, very low-quality evidence).We found no studies that evaluated all-cause mortality within 30 days from the lumbar puncture procedure, length of hospital stay, proportion of participants who received platelet transfusions, or quality of life.

AUTHORS' CONCLUSIONS

We found no evidence from RCTs or non-randomised studies on which to base an assessment of the correct platelet transfusion threshold prior to insertion of a lumbar puncture needle or epidural catheter. There are no ongoing registered RCTs assessing the effects of different platelet transfusion thresholds prior to the insertion of a lumbar puncture or epidural anaesthesia in people with thrombocytopenia. Any future study would need to be very large to detect a difference in the risk of bleeding. A study would need to be designed with at least 47,030 participants to be able to detect an increase in the number of people who had major procedure-related bleeding from 1 in 1000 to 2 in 1000. The use of a central data collection register or routinely collected electronic records (big data) is likely to be the only method to systematically gather data relevant to this population.

Risk of Epidural Hematoma after Neuraxial Techniques in Thrombocytopenic Parturients: A Report from the Multicenter Perioperative Outcomes Group

BACKGROUND

Thrombocytopenia has been considered a relative or even absolute contraindication to neuraxial techniques due to the risk of epidural hematoma. There is limited literature to estimate the risk of epidural hematoma in thrombocytopenic parturients. The authors reviewed a large perioperative database and performed a systematic review to further define the risk of epidural hematoma requiring surgical decompression in this population.

METHODS

The authors performed a retrospective cohort study using the Multicenter Perioperative Outcomes Group database to identify thrombocytopenic parturients who received a neuraxial technique and to estimate the risk of epidural hematoma. Patients were stratified by platelet count, and those requiring surgical decompression were identified. A systematic review was performed, and risk estimates were combined with those from the existing literature.

RESULTS

A total of 573 parturients with a platelet count less than 100,000 mm who received a neuraxial technique across 14 institutions were identified in the Multicenter Perioperative Outcomes Group database, and a total of 1,524 parturients were identified after combining the data from the systematic review. No cases of epidural hematoma requiring surgical decompression were observed. The upper bound of the 95% CI for the risk of epidural hematoma for a platelet count of 0 to 49,000 mm is 11%, for 50,000 to 69,000 mm is 3%, and for 70,000 to 100,000 mm is 0.2%.

CONCLUSIONS

The number of thrombocytopenic parturients in the literature who received neuraxial techniques without complication has been significantly increased. The risk of epidural hematoma associated with neuraxial techniques in parturients at a platelet count less than 70,000 mm remains poorly defined due to limited observations.

Regional anesthesia in patients with pregnancy induced hypertension

Pregnancy induced hypertension is a hypertensive disorder, which occurs in 5% to 7% of all pregnancies. These parturients present to the labour and delivery unit ranging from gestational hypertension to HELLP syndrome. It is essential to understand the various clinical conditions that may mimic preeclampsia and the urgency of cesarean delivery, which may improve perinatal outcome. The administration of general anesthesia (GA) increases morbidity and mortality in both mother and baby. The provision of regional anesthesia when possible maintains uteroplacental blood flow, avoids the complications with GA, improves maternal and neonatal outcome. The use of ultrasound may increase the success rate. This review emphasizes on the regional anesthetic considerations when such parturients present to the labor and delivery unit.

Anaesthesia for Caesarean Section of Pregnant Women with Idiopathic Thrombocytopenic Purpura

Women with idiopathic thrombocytopenic purpura (ITP) may become pregnant, or the disease may occur for the first time during pregnancy. Thrombocytopenia is usually noticed in the first months of pregnancy and the platelet count is often quite low. In this case report, we described the anaesthetic method for caesarean section in a pregnant woman at 38 weeks of gestation with refractory ITP.

Subarachnoid block for caesarean section in severe preeclampsia

Pregnancy-induced hypertension constitutes a major cause of morbidity and mortality in developing nations and it complicates about 6–8% of pregnancies. Severe preeclampsia poses a dilemma for the anesthesiologist especially in emergency situations where caesarean deliveries are planned for uninvestigated or partially investigated parturients. This article is aimed to review the literature with regards to the type of anesthesia for such situations. A thorough search of literature was conducted on PubMed, EMBASE, and Google to retrieve the articles. Studies on parturients with severe preeclampsia, undergoing caesarean section, were included in this article. There is growing evidence to support the use of subarachnoid block in such situations when the platelet counts are >80,000 mm^-3. Better hemodynamic stability with the use of low-dose local anesthetic along with additives and better neonatal outcomes has been found with the use of subarachnoid block when compared to general anesthesia.

Severe Thrombocytopenia in an Immune Thrombocytopenic Parturient Non-responder to Medical Line of Treatment: Anaesthetic Management for Splenectomy Combined with Caesarean Section

We report anaesthesia management of a parturient with severe thrombocytopenia secondary to immune thrombocytopenic purpura (ITP). Her platelet count remained around 3 × 10(9)/l in spite of optimum medical therapy and hence was posted for splenectomy combined with caesarean section. Anaesthesia implications of severe thrombocytopenia comprises risk of central nervous system bleeding, perioperative haemorrhage causing placental hypoperfusion and foetal hypoxia, risk of trauma to compromised airway and risk of epidural haematoma. The purpose of this paper is to discuss the risk factors associated, different management strategies and also to review the literature in an attempt to ameliorate the anaesthesiologist in perioperative management of these cases.

Anesthetic considerations in a patient of autosomal dominant polycystic kidney disease on hemodialysis for emergency cesarean section

Renal disease, either preexisting or occurring during gestation may impair maternal and fetal health. A 35-year-old primigravida with autosomal dominant polycystic kidney disease on hemodialysis was scheduled for emergency cesarean section. She was managed successfully with low-dose intrathecal bupivacaine and fentanyl. In the case of pregnancy in such a patient, early involvement of the nephrologists along with the obstetrician can improve maternal and fetal outcome.

Immune thrombocytopenia in pregnancy

Management of immune thrombocytopenia in pregnancy can be a complex and challenging task and may be complicated by fetal-neonatal thrombocytopenia. Although fetal intracranial hemorrhage is a rare complication of immune thrombocytopenia in pregnancy, invasive studies designed to determine the fetal platelet count before delivery are associated with greater risk than that of fetal intracranial hemorrhage and are discouraged. Moreover, the risk of neonatal bleeding complications does not correlate with the mode of delivery, and cesarean section should be reserved only for obstetric indications.

Retrospective audit of outcome of regional anesthesia for delivery in women with thrombocytopenia

Regional anesthesia for pain at delivery in the presence of maternal thrombocytopenia is a clinical dilemma. We reviewed 10,369 obstetric cases (12 months) from our tertiary center. Generally, hemodilution of pregnancy does not result in thrombocyte counts of <150,000/mm(3) at delivery. A total of 166 births (1.6%) were recorded in women with thrombocytes <150,000/mm(3) at delivery. Parturients with >150,000/mm(3) at week 36 were separated post hoc (n=35; 21%) and the remaining parturients were divided as having <100,000/mm(3) (n=30; 18%) or 101,000-150,000/mm(3) (n=101; 60.5%). Epidural or spinal anesthesia was administered to 30% women with <100,000/mm(3) whereas 56% women with >101,000/mm(3) received these options (P=0.003). A total of 13.9% of parturients with trimester-long thrombocytopenia required blood products; 10/23 (43.5%) parturients undergoing cesarean section also required blood products (P=0.000). Four of six babies with Apgar scores of <or=7 at 1-min were born to women with platelets <100,000/mm(3) (P=0.009). There were no statistically significant differences in mean birth weights. Women with thrombocytes <150,000/mm(3) at birth but within the normal range at week 36 were more likely multiparas (P=0.001). We conclude that a difference in maternal and neonatal outcomes exists between mothers who were thrombocytopenic only at delivery compared to those with trimester-long thrombocytopenia, with the latter mothers and babies having more adverse events.

Best practice in primary care pathology: review 3

This best practice review examines four series of common primary care questions in laboratory medicine: (i) "minor" blood platelet count and haemoglobin abnormalities; (ii) diagnosis and monitoring of anaemia caused by iron deficiency; (iii) secondary hyperlipidaemia and hypertriglyceridaemia; and (iv) glycated haemoglobin and microalbumin use in diabetes. The review is presented in question-answer format, referenced for each question series. The recommendations represent a précis of guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents and evidence-based medicine reviews, supplemented by Medline Embase searches to identify relevant primary research documents. They are not standards, but form a guide to be set in the clinical context. Most of the recommendations are based on consensus rather than evidence. They will be updated periodically to take account of new information.

Management of Adult Idiopathic Thrombocytopenic Purpura

Idiopathic thrombocytopenic purpura (ITP) is a common hematologic disorder manifested by immune-mediated thrombocytopenia. The diagnosis remains one of exclusion, after other thrombocytopenic disorders are ruled out based on history, physical examination, and laboratory evaluation. The goal of treatment is to raise the platelet count into a hemostatically safe range. The disorder is usually chronic, although there is considerable variation in the clinical course and most patients eventually attain safe platelet counts off treatment. However, a subset of patients has severe disease refractory to all treatment modalities, which is associated with considerable morbidity and mortality. This article focuses on the management of primary ITP in adults. We discuss criteria for treatment, the roles of splenectomy and other treatment options along with their side effects, and the management of ITP during pregnancy.

Preeclampsia. Part 1: clinical and pathophysiologic considerations

Preeclampsia-eclampsia is still one of the leading causes of maternal and fetal morbidity and mortality. Despite active research for many years, the etiology of this disorder exclusive to human pregnancy is an enigma. Recent evidence suggests there may be several underlying causes or predispositions leading to the signs of hypertension, proteinuria, and edema, findings that allow us to make the diagnosis of the "syndrome" of preeclampsia. Despite improved prenatal care, severe preeclampsia and eclampsia still occur. Although understanding of the pathophysiology of these disorders has improved, treatment has not changed significantly in over 50 years. Although postponement of delivery in selected women with severe preeclampsia improves fetal outcome to a degree, this is not done without risk to the mother. In the United States, magnesium sulfate and hydralazine are the most commonly used medications for seizure prophylaxis and hypertension in the intrapartum period. The search for the underlying cause of this disorder and for a clinical marker to predict those women who will develop preeclampsia-eclampsia is ongoing, with its prevention the ultimate goal. This review begins with the clinical and pathophysiologic aspects of preeclampsia-eclampsia (Part 1). In Part 2, the experimental observations, the search for predictive factors, and the genetics of this disorder will be reviewed.

Management of pre-eclampsia and haemolysis, elevated liver enzymes, and low platelets syndrome

Pre-eclampsia remains a major cause of maternal and fetal ill-health. Defective placentation and endothelial dysfunction appear to underlie the clinical features. Recent publications regarding the diagnosis, treatment, prediction and prevention of pre-eclampsia, and contemporary issues in the management of the haemolysis, elevated liver enzymes, and low platelets syndrome, are discussed in this review.