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

Risk-based and individualised management of bleeding and thrombotic events in adults with primary immune thrombocytopenia (ITP)

Although bleeding is one of the main symptoms of primary immune thrombocytopenia (ITP), risk factors for bleeding have yet to be fully established. Low platelet count (PC; <20-30 × 109 /L) is generally indicative of increased risk of bleeding. However, PC and bleeding events cannot be fully correlated; many other patient- and disease-related factors are thought to contribute to increased bleeding risk. Furthermore, even though ITP patients have thrombocytopenia and are at increased risk of bleeding, ITP also carries higher risk of thrombotic events. Factors like older age and certain ITP treatments are associated with increased thrombotic risk. Women's health in ITP requires particular attention concerning haemorrhagic and thrombotic complications. Management of bleeding/thrombotic risk, and eventually antithrombotic therapies in ITP patients, should be based on individual risk profiles, using a tailored, patient-centric approach. Currently, evidence-based recommendations and validated tools are lacking to support decision-making and help clinicians weigh risk of bleeding against thrombosis. Moreover, evidence is lacking about optimal PC for achieving haemostasis in invasive procedures settings. Further research is needed to fully define risk factors for each event, enabling development of comprehensive risk stratification approaches. This review discusses risk-based and individualised management of bleeding and thrombosis risk in adults with primary ITP.

Hypertensive Disorders of Pregnancy

According to the American College of Obstetricians and Gynecologists (ACOG), women who have a systolic blood pressure ≥ 140 mm Hg and/or a diastolic pressure ≥ 90 mm Hg before pregnancy or before 20 weeks of gestation have chronic hypertension. Up to 1.5% of women in their childbearing years have a diagnosis of chronic hypertension, and 16% of pregnant women develop hypertension during their pregnancy. Physiological cardiovascular changes from pregnancy may mask or exacerbate hypertensive diseases during gestation, which is why prepregnancy counseling is emphasized for all patients to optimize comorbidities and establish a patient's baseline blood pressure. This review provides an overview of the diagnoses and treatments of hypertensive diseases that can occur in pregnancy, including definitions of key terms and types of hypertension as well as ACOG recommendations.

Complications of Spinal Cord Stimulator Trials and Implants: A Review

PURPOSE OF REVIEW

Spinal cord stimulation (SCS) has been used for decades to alleviate chronic pain. A growing body of literature suggests that the procedure is not without risks. Understanding the risks of SCS implantation can help treating physicians formulate individualized care plans that promote patient safety and minimize risks.

RECENT FINDINGS

The overall complication rate associated with SCS has been reported to be 31.9 to 43%. The most common complication in the literature appears to be electrode migration. Other complications ranging in rates of occurrence include hematoma formation, infection, spinal cord injury, and cerebrospinal fluid (CSF) leak. Case reports of syrinx formation, foreign body reaction, and fibrosis have also been described. Our review shows that there are strategies available to reduce and prevent complications. In addition, close monitoring and early intervention may prevent some of the adverse neurological outcomes. Nevertheless, additional research regarding patient and procedural factors is necessary to improve the safety profile of this intervention.

Optimizing Delivery Strategies in Eclampsia: A Comprehensive Review on Seizure Management and Birth Methods

Eclampsia seizure is an always serious and potentially fatal obstetric condition. Safe delivery in women with pregnancies complicated by eclampsia seizures is still one of the greatest challenges in perinatal medicine. Pregnancy should be terminated (childbirth) in the safest and least traumatic way possible. Attempting vaginal delivery can take place only exceptionally, in the event of possibly quick completion of childbirth with a stable state of the mother and the fetus. However, immediate labor via cesarean section is most often recommended. It is essential to maintain left lateral patient positioning during cesarean section. Regional anesthesia can be used only in conscious patients who are free from coagulopathy and from HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome to decrease the risk of aspiration and failed intubation attempts in preeclamptic or eclamptic women. For sudden, unexpected interventions, when a patient arrives at the hospital with an eclampsia seizure without lab results, general anesthesia can be the best option and should be performed by an experienced medical team of anesthesiologists, ready to perform difficult intubation. Magnesium sulfate is the drug that should be used first to stop eclamptic convulsions and prevent their recurrence. Intravenous antihypertensive drugs can stabilize elevated blood pressure (BP), preventing multiorgan failure and recurrent eclampsia seizure, and thus the prevention of maternal death. This article aims to review the management of seizures during pregnancy in women with eclampsia to ensure safe delivery.

Machine Learning for the Prediction of Procedural Case Durations Developed Using a Large Multicenter Database: Algorithm Development and Validation Study

BACKGROUND

Accurate projections of procedural case durations are complex but critical to the planning of perioperative staffing, operating room resources, and patient communication. Nonlinear prediction models using machine learning methods may provide opportunities for hospitals to improve upon current estimates of procedure duration.

OBJECTIVE

The aim of this study was to determine whether a machine learning algorithm scalable across multiple centers could make estimations of case duration within a tolerance limit because there are substantial resources required for operating room functioning that relate to case duration.

METHODS

Deep learning, gradient boosting, and ensemble machine learning models were generated using perioperative data available at 3 distinct time points: the time of scheduling, the time of patient arrival to the operating or procedure room (primary model), and the time of surgical incision or procedure start. The primary outcome was procedure duration, defined by the time between the arrival and the departure of the patient from the procedure room. Model performance was assessed by mean absolute error (MAE), the proportion of predictions falling within 20% of the actual duration, and other standard metrics. Performance was compared with a baseline method of historical means within a linear regression model. Model features driving predictions were assessed using Shapley additive explanations values and permutation feature importance.

RESULTS

A total of 1,177,893 procedures from 13 academic and private hospitals between 2016 and 2019 were used. Across all procedures, the median procedure duration was 94 (IQR 50-167) minutes. In estimating the procedure duration, the gradient boosting machine was the best-performing model, demonstrating an MAE of 34 (SD 47) minutes, with 46% of the predictions falling within 20% of the actual duration in the test data set. This represented a statistically and clinically significant improvement in predictions compared with a baseline linear regression model (MAE 43 min; P<.001; 39% of the predictions falling within 20% of the actual duration). The most important features in model training were historical procedure duration by surgeon, the word "free" within the procedure text, and the time of day.

CONCLUSIONS

Nonlinear models using machine learning techniques may be used to generate high-performing, automatable, explainable, and scalable prediction models for procedure duration.

Genetic predisposition may not improve prediction of cardiac surgery-associated acute kidney injury

Background: The recent integration of genomic data with electronic health records has enabled large scale genomic studies on a variety of perioperative complications, yet genome-wide association studies on acute kidney injury have been limited in size or confounded by composite outcomes. Genome-wide association studies can be leveraged to create a polygenic risk score which can then be integrated with traditional clinical risk factors to better predict postoperative complications, like acute kidney injury. Methods: Using integrated genetic data from two academic biorepositories, we conduct a genome-wide association study on cardiac surgery-associated acute kidney injury. Next, we develop a polygenic risk score and test the predictive utility within regressions controlling for age, gender, principal components, preoperative serum creatinine, and a range of patient, clinical, and procedural risk factors. Finally, we estimate additive variant heritability using genetic mixed models. Results: Among 1,014 qualifying procedures at Vanderbilt University Medical Center and 478 at Michigan Medicine, 348 (34.3%) and 121 (25.3%) developed AKI, respectively. No variants exceeded genome-wide significance (p < 5 × 10-8) threshold, however, six previously unreported variants exceeded the suggestive threshold (p < 1 × 10-6). Notable variants detected include: 1) rs74637005, located in the exonic region of NFU1 and 2) rs17438465, located between EVX1 and HIBADH. We failed to replicate variants from prior unbiased studies of post-surgical acute kidney injury. Polygenic risk was not significantly associated with post-surgical acute kidney injury in any of the models, however, case duration (aOR = 1.002, 95% CI 1.000-1.003, p = 0.013), diabetes mellitus (aOR = 2.025, 95% CI 1.320-3.103, p = 0.001), and valvular disease (aOR = 0.558, 95% CI 0.372-0.835, p = 0.005) were significant in the full model. Conclusion: Polygenic risk score was not significantly associated with cardiac surgery-associated acute kidney injury and acute kidney injury may have a low heritability in this population. These results suggest that susceptibility is only minimally influenced by baseline genetic predisposition and that clinical risk factors, some of which are modifiable, may play a more influential role in predicting this complication. The overall impact of genetics in overall risk for cardiac surgery-associated acute kidney injury may be small compared to clinical risk factors.

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.

Analgesia in Pregnancy

Pain management during labor and delivery is complex and must balance efficacy and toxicity to both the pregnant person and the fetus. There are numerous ways to achieve safe and effective analgesia and anesthesia during labor and delivery, including neuraxial and nonneuraxial techniques. This review describes important anesthetic considerations that should be made when formulating a pain management plan and an overview of common anesthesia-related complications encountered in the obstetric population.

Interaction Between Platelet and Fibrinogen on Clot Strength in Healthy Patients

OBJECTIVE

The purpose of this study was to explore the relationship between platelet concentration (PLT) (× 10⁹/L) and clot strength measured by thromboelastography maximum amplitude (TEG-MA) in healthy volunteers without a history of coagulation abnormalities. Secondarily, the relationship between fibrinogen (mg/dL) and TEG-MA was analyzed.

DESIGN

A prospective study.

SETTING

At a university's tertiary-care center.

MEASUREMENTS AND MAIN RESULTS

Using whole blood, PLT was reduced in the first part, and hematocrit was reduced in the second part of the study by hemodilution with platelet-rich and -poor plasma. Thromboelastography (TEG 5000 Haemonetics) was performed to measure clot formation and strength. Spearman correlation coefficients regression analyses and receiver-operating characteristics (ROC) were obtained to analyze the relationships among PLT, fibrinogen, and TEG-MA. Strong correlations were found in univariate analysis between PLT and TEG-MA (r = 0.88; p < 0.0001) and between Fibrinogen and TEG-MA (r = 0.70; p = 0.003). A biphasic relationship between PLT and TEG-MA was linear below a PLT 90 × 10⁹/L, followed by a plateau above 100 × 10⁹/L (p = 0.001). A linear relationship between fibrinogen (190-474 mg/dL) and TEG-MA (53-76 mm) was found (p = 0.0007). The ROC analysis found that PLT = 60 × 10⁹/L was associated with a TEG-MA of 53.0 mm. The product of PLT and fibrinogen concentrations was more strongly correlated (r = 0.91) to TEG-MA than either PLT (r = 0.86) or fibrinogen (r = 0.71) alone. A ROC analysis revealed that a TEG-MA of 55 mm was associated with a PLT × fibrinogen of 16,720.

CONCLUSION

In healthy patients, a PLT of 60 × 10⁹/L was associated with normal clot strength (TEG-MA ≥53 mm), and there was little change in clot strength with PLT >90 × 10⁹/L. Although prior analyses described the contributions of platelets and fibrinogen toward clot strength, they are presented and discussed independently. The data above described clot strength as an interaction among them. Future analyses and clinical care should evaluate and recognize the interplay.

What Is New in Obstetric Anesthesia: The 2021 Gerard W. Ostheimer Lecture

The Gerard W. Ostheimer lecture is given annually to members of the Society for Obstetric Anesthesia and Perinatology. This lecture summarizes new and emerging literature that informs the clinical practice of obstetric anesthesiologists. In this review, some of the most influential articles discussed in the 2021 virtual lecture are highlighted. Themes include maternal mortality; disparities and social determinants of health; cognitive function, mental health, and recovery; quality and safety; operations, value, and economics; clinical controversies and dogmas; epidemics and pandemics; fetal-neonatal and child health; general clinical care; basic and translational science; and the future of peripartum anesthetic care. Practice-changing evidence is presented and evaluated. A priority list for clinical updates, systems, and quality improvement initiatives is presented.

General Anesthesia for Cesarean Delivery for Thrombocytopenia in Hypertensive Disorders of Pregnancy: Findings From the Obstetric Airway Management Registry

BACKGROUND

In resource-limited environments, spinal anesthesia (SA) is preferred for cesarean delivery. In women at risk of spinal epidural hematoma, particularly those with hypertensive disorders of pregnancy, thrombocytopenia should be excluded before neuraxial blockade. In the context of emergency surgery for fetal distress, this investigation may be hampered by laboratory services being unavailable or off-site.

METHODS

The Obstetric Airway Management Registry (ObAMR) is currently active across all anesthesia training institutions affiliated with the University of Cape Town. This multicenter observational study aimed to estimate the proportion of patients receiving general anesthesia (GA) for either confirmed or suspected thrombocytopenia, which was not excluded due to unavailability of laboratory results. To establish the number of GA uses that may have been avoided if platelet counts were available, we retrospectively searched for subsequent platelet counts in patients for whom thrombocytopenia was suspected. An algorithm was proposed, including a simple decision aid for estimating risk versus benefit of SA versus GA, to be followed in the setting of hypertensive disorders of pregnancy and thrombocytopenia.

RESULTS

Thrombocytopenia was the indication for GA in 100 of 591 patients (16.9%) captured in the registry. In total, 48 of 591 (8.1%) had confirmed thrombocytopenia, and 52 of 591 (8.8%) had suspected thrombocytopenia. Of these patients, 91 of 100 had a hypertensive disorder of pregnancy. In the confirmed thrombocytopenia group, the indication for GA was a platelet count <75 × 109/L. In the suspected thrombocytopenia group, 46 of 52 (88.5%) platelet counts could be retrospectively traced. The median (interquartile range) platelet count was 178 × 109/L (93 - 233 × 109/L), and platelets exceeded 75 × 109/L in 41 of 46 patients (89.1%). In the 5 of 46 patients with retrospectively confirmed thrombocytopenia, 2 had hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome, 2 had antepartum hemorrhage with preeclampsia, and 1 had isolated thrombocytopenia with preeclampsia.

CONCLUSIONS

In 17% of patients, the indication for GA was thrombocytopenia. Of these, 52 of 100, or nearly 9% of the total of 591, received GA because a platelet count was unavailable at the time of surgery. The importance of early laboratory assessment, when available, should be emphasized. Overall, 41 of 591 (6.9%) had a platelet count >75 × 109/L and would not have needed GA if their platelet count had been known. After following the constructed algorithm and applying the decision aid to assess risk and benefit, there may be circumstances in which the clinician justifiably opts for SA when a platelet count is indicated but unavailable.

Association of propofol induction dose and severe pre-incision hypotension among surgical patients over age 65

STUDY OBJECTIVE

We aimed to study the association between propofol induction dose (mg/kg) and pre-incision severe hypotension (Mean Arterial Pressure (MAP) ≤ 55 mmHg) among patients ≥65 years of age.

DESIGN

Retrospective Observational.

SETTING

40 centers participating in the Multicenter Perioperative Outcomes Group consortium.

PATIENTS

Patients ≥65 years of age undergoing non-cardiac, non-vascular surgery who received propofol for general anesthetic induction prior to endotracheal intubation between January 2014 and December 2018.

INTERVENTIONS

None.

MEASUREMENTS

The primary exposure was total propofol induction dose in mg/kg, and the primary outcome was occurrence of severe hypotension (MAP≤55 mmHg) prior to surgical incision, stratified by non-invasive vs. invasive blood pressure monitoring type.

MAIN RESULTS

Among 320,585 total patients, 22.6% experienced the outcome of pre-incision severe hypotension (MAP≤55 mmHg). When stratified by blood pressure monitoring type, 20.7% with non-invasive blood pressure measurements, and 35.0% with invasive blood pressure measurements had the outcome. After controlling for a variety of patient and procedural factors, there was a significant independent association between propofol induction dose and pre-incision hypotension (Non-invasive blood pressure cohort odds ratio (OR) 1.10; 95% confidence interval (CI) 1.07 to 1.13; p < 0.001; and Invasive blood pressure cohort OR 1.15; 95%CI 1.10 to 1.21; adjusted p < 0.001). The association was robust to alternative definitions of the outcome, including less severe hypotension (MAP≤65 mmHg) and blood pressure drop from baseline as a continuous measure. Although no threshold safe induction dose was identified at which hypotension was avoided, an analysis of propofol dose greater or less than 1.5 mg/kg (i.e. the maximum FDA-defined typical induction dose) demonstrated that doses in excess of the FDAs threshold were positively associated with odds of severe hypotension (Non-invasive cohort: OR 1.05; 95% CI 1.02 to 1.08; p < 0.001; Invasive cohort: OR 1.11; 95%CI 1.05 to 1.17; adjusted p < 0.001).

CONCLUSIONS

In a multicenter cohort of geriatric surgical patients receiving propofol for general anesthetic induction and endotracheal intubation, severe pre-incision hypotension (MAP ≤55 mmHg) that has previously been associated with postoperative morbidity was common. The dose of propofol used was significantly associated with increased odds of this outcome after controlling for a number of clinically relevant factors. Future studies that are designed to test different approaches to anesthesia induction for reducing severe post induction pre-incision hypotension are warranted.

Unexpected Thrombocytopenia in a Parturient With Evans Syndrome Complicated by COVID-19 Infection

We report the case of a 23-year-old parturient who received epidural analgesia and was subsequently diagnosed with Evans syndrome (ES). The diagnosis was made after a complete blood count (CBC) resulted in severe anemia and a platelet count of less than 10K/µL. To further complicate this case, the patient developed post-delivery pleuritic chest pain and pulmonary emboli (PE), and a chest computed tomography (CT) scan showed bilateral ground-glass lung opacities. This prompted a COVID-19 testing and ultimately confirmed infection.

Assessment of Perioperative Outcomes Among Surgeons Who Operated the Night Before

IMPORTANCE

The association between physician fatigue and patient outcomes is important to understand but has been difficult to examine given methodological and data limitations. Surgeons frequently perform urgent procedures overnight and perform additional procedures the following day, which could adversely affect outcomes for those daytime operations.

OBJECTIVE

To examine the association between an attending surgeon operating overnight and outcomes for operations performed by that surgeon the next day.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, a retrospective analysis of a large multicenter registry of surgical procedures was done using a within-surgeon analysis to address confounding, with data from 20 high-volume US institutions. This study included 498 234 patients who underwent a surgical procedure during the day (between 7 am and 5 pm) between January 1, 2010, and August 30, 2020.

EXPOSURES

Whether the attending surgeon for the current day's procedures operated between 11 pm and 7 am the previous night. Two exposure measures were examined: whether the surgeon operated at all the previous night and the number of hours spent operating the previous night (including having performed no work at all).

MAIN OUTCOMES AND MEASURES

The primary composite outcome was in-hospital death or major complication (sepsis, pneumonia, myocardial infarction, thromboembolic event, or stroke). Secondary outcomes included operation length and individual outcomes of death, major complications, and minor complications (surgical site infection or urinary tract infection).

RESULTS

Among 498 234 daytime operations performed by 1131 surgeons, 13 098 (2.6%) involved an attending surgeon who operated the night before. The mean (SD) age of the patients who underwent an operation was 55.3 (16.4) years, and 264 740 (53.1%) were female. After adjusting for operation type, surgeon fixed effects, and observable patient characteristics (ie, age and comorbidities), the adjusted incidence of in-hospital death or major complications was 5.89% (95% CI, 5.41%-6.36%) among daytime operations when the attending surgeon operated the night before compared with 5.87% (95% CI, 5.85%-5.89%) among daytime operations when the same surgeon did not (absolute adjusted difference, 0.02%; 95% CI, -0.47% to 0.51%; P = .93). No significant associations were found between overnight work and secondary outcomes except for operation length. Operating the previous night was associated with a statistically significant decrease in length of daytime operations (adjusted length, 112.7 vs 117.4 minutes; adjusted difference, -4.7 minutes; 95% CI, -8.7 to -0.8, P = .02), although this difference is unlikely to be meaningful.

CONCLUSIONS AND RELEVANCE

The findings of this cross-sectional study suggest that operating overnight was not associated with worse outcomes for operations performed by surgeons the subsequent day. These results provide reassurance concerning the practice of having attending surgeons take overnight call and still perform operations the following morning.

An Overview of Commonly Used Data Sources in Observational Research in Anesthesia

Anesthesia research using existing databases has drastically expanded over the last decade. The most commonly used data sources in multi-institutional observational research are administrative databases and clinical registries. These databases are powerful tools to address research questions that are difficult to answer with smaller samples or single-institution information. Given that observational database research has established itself as valuable field in anesthesiology, we systematically reviewed publications in 3 high-impact North American anesthesia journals in the past 5 years with the goal to characterize its scope. We identified a wide range of data sources used for anesthesia-related research. Research topics ranged widely spanning questions regarding optimal anesthesia type and analgesic protocols to outcomes and cost of care both on a national and a local level. Researchers should choose their data sources based on various factors such as the population encompassed by the database, ability of the data to adequately address the research question, budget, acceptable limitations, available data analytics resources, and pipeline of follow-up studies.

Frequency and Risk Factors for Difficult Intubation in Women Undergoing General Anesthesia for Cesarean Delivery: A Multicenter Retrospective Cohort Analysis

BACKGROUND

Estimates for the incidence of difficult intubation in the obstetric population vary widely, though prior studies reporting rates of difficult intubation in obstetrics are older and limited by smaller samples. The goals of this study were to provide a contemporary estimate of the frequency of difficult and failed intubation in women undergoing general anesthesia for cesarean delivery and to elucidate risk factors for difficult intubation in women undergoing general anesthesia for cesarean delivery.

METHODS

This is a multicenter, retrospective cohort study utilizing the Multicenter Perioperative Outcomes Group database. The study population included women aged 15-44 undergoing general anesthesia for cesarean delivery between 2004 and 2019 at one of 45 medical centers. Co-primary outcomes included the frequencies of difficult and failed intubation. Difficult intubation was defined as Cormack-Lehane view ≥3, intubation attempts ≥3, rescue fiberoptic intubation, rescue supraglottic airway, or surgical airway. Failed intubation was defined as any attempt at intubation without successful endotracheal tube placement. Rates of difficult and failed intubation were assessed. Several patient demographic, anatomical, and obstetric factors were evaluated for potential associations with difficult intubation.

RESULTS

We identified 14,748 cases of cesarean delivery performed under general anesthesia. There were 295 cases of difficult intubation, with a frequency of 1:49 (95% CI: 1:55, 1:44) (n=14,531). There were 18 cases of failed intubation, with a frequency of 1:808 (95% CI: 1:1,276, 1:511) (n=14,537). Factors with the highest point estimates for the odds of difficult intubation included increased body mass index, Mallampati score III or IV, small hyoid to mentum distance, limited jaw protrusion, limited mouth opening, and cervical spine limitations.

CONCLUSIONS

In this large, multi-center, contemporary study of over 14,000 general anesthetics for cesarean delivery, we observed an overall risk of difficult intubation of 1:49 and a risk of failed intubation of 1:808. Most risk factors for difficult intubation were non-obstetric in nature. These data demonstrate that difficult intubation in obstetrics remains an ongoing concern.

Eclampsia in the 21st century

The reported incidence of eclampsia is 1.6 to 10 per 10,000 deliveries in developed countries, whereas it is 50 to 151 per 10,000 deliveries in developing countries. In addition, low-resource countries have substantially higher rates of maternal and perinatal mortalities and morbidities. This disparity in incidence and pregnancy outcomes may be related to universal access to prenatal care, early detection of preeclampsia, timely delivery, and availability of healthcare resources in developed countries compared to developing countries. Because of its infrequency in developed countries, many obstetrical providers and maternity units have minimal to no experience in the acute management of eclampsia and its complications. Therefore, clear protocols for prevention of eclampsia in those with severe preeclampsia and acute treatment of eclamptic seizures at all levels of healthcare are required for better maternal and neonatal outcomes. Eclamptic seizure will occur in 2% of women with preeclampsia with severe features who are not receiving magnesium sulfate and in <0.6% in those receiving magnesium sulfate. The pathogenesis of an eclamptic seizure is not well understood; however, the blood-brain barrier disruption with the passage of fluid, ions, and plasma protein into the brain parenchyma remains the leading theory. New data suggest that blood-brain barrier permeability may increase by circulating factors found in preeclamptic women plasma, such as vascular endothelial growth factor and placental growth factor. The management of an eclamptic seizure will include supportive care to prevent serious maternal injury, magnesium sulfate for prevention of recurrent seizures, and promoting delivery. Although routine imagining following an eclamptic seizure is not recommended, the classic finding is referred to as the posterior reversible encephalopathy syndrome. Most patients with posterior reversible encephalopathy syndrome will show complete resolution of the imaging finding within 1 to 2 weeks, but routine imaging follow-up is unnecessary unless there are findings of intracranial hemorrhage, infraction, or ongoing neurologic deficit. Eclampsia is associated with increased risk of maternal mortality and morbidity, such as placental abruption, disseminated intravascular coagulation, pulmonary edema, aspiration pneumonia, cardiopulmonary arrest, and acute renal failure. Furthermore, a history of eclamptic seizures may be related to long-term cardiovascular risk and cognitive difficulties related to memory and concentration years after the index pregnancy. Finally, limited data suggest that placental growth factor levels in women with preeclampsia are superior to clinical markers in prediction of adverse pregnancy outcomes. This data may be extrapolated to the prediction of eclampsia in future studies. This summary of available evidence provides data and expert opinion on possible pathogenesis of eclampsia, imaging findings, differential diagnosis, and stepwise approach regarding the management of eclampsia before delivery and after delivery as well as current recommendations for the prevention of eclamptic seizures in women with preeclampsia.

Labor epidural analgesia with severe thrombocytopenia

Thrombocytopenia in pregnancy could potentially lead to epidural hematoma and associated morbidity when neuraxial anesthesia is performed. We present a case of a 24-year-old parturient, who was otherwise healthy and without prior thrombocytopenia, who underwent epidural placement in the setting of undiagnosed severe thrombocytopenia. Her workup remained inconclusive, and the presumptive diagnosis of severe preeclampsia was made. She was given a platelet transfusion and underwent an uncomplicated spontaneous vaginal delivery. After recovery of her platelet count, the epidural catheter was safely removed approximately 60 hours after placement without any signs or symptoms of an epidural hematoma.

Neuraxial Techniques for Parturients with Thromboprophylaxis or Thrombocytopenia

Pharmacologic thromboprophylaxis from venous thromboembolism (VTE) and thrombocytopenia in pregnancy results in conditions that may preclude the use of neuraxial anesthesia due to a perceived risk of spinal/epidural hematoma. Spinal epidural hematoma is a recognized complication in patients who are hypocoagulable and may lead patients to undergo general anesthesia for delivery or other procedures, which carries numerous complications in obstetric care. A robust understanding of maternal physiologic changes in coagulation status, review of consensus statements, and safety bundles may help to maximize the use of neuraxial anesthesia in obstetric patients who might otherwise be denied these anesthetic techniques.

Preeclampsia in 2021-a Perioperative Medical Challenge for the Anesthesiologist

The authors provide a review of recent advances in the understanding of pathophysiology and perioperative management of preeclampsia and eclampsia, from the perspective of the anesthesiologist. This review includes aspects of assessment of severity of disease, hemodynamic monitoring, peripartum anesthesia care, and postpartum management. The perioperative management of patients with eclampsia is also discussed.

Moderate to Severe Thrombocytopenia in Four Pregnant Women With Asymptomatic COVID-19 Infection

Coronavirus disease 2019 (COVID-19) pandemic is one of the biggest healthcare crises faced globally. Since its emergence, uncertainty about its progress and treatment options has challenged clinicians around the world. Pregnant women infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection pose a higher challenge due to the concerns of an already altered immune system during pregnancy and the disease's effect on the fetus. Thrombocytopenia is associated frequently with moderate to severe coronavirus disease and is also an established marker of worsening of the disease. However, it is infrequently seen in mild or asymptomatic cases.

Neuraxial anesthesia is the preferred choice of anesthesia in COVID-19 positive patients but thrombocytopenia in a parturient with coronavirus disease can cause a dilemma for the obstetric anesthesiologist. Here we describe the management of four pregnant women with asymptomatic COVID-19 disease who had moderate to severe thrombocytopenia. These cases highlight the importance of careful monitoring of the platelet count of pregnant women with COVID-19 infection even if asymptomatic.

Analgesic considerations for induction of labor

Induction of labor may be indicated to minimize maternal and fetal risks. The rate of induction is likely to increase as recent evidence supports elective induction at 39 weeks gestation. We review methods of induction and then analgesic options as they relate to indications and methods to induce labor. We specifically focus on parturients at high risk for anesthetic complications including those requiring anticoagulation, and those with cardiac disease, obesity, chorioamnionitis, prior spinal instrumentation, elevated intracranial pressure, known or anticipated difficult airway, thrombocytopenia, and preeclampsia. Guidelines regarding timing of anticoagulation dosing with neuraxial anesthetic techniques have been defined through consensus statements. Early epidural placement may be beneficial in patients with cardiac disease, obesity, anticipated difficult airway, and HELLP syndrome. Questions remain regarding how early is too early for epidural placement, what options are safest for patients with bacteremia, and what pain relief should be offered to those unable to tolerate cervical exams in early labor.

Variation in propofol induction doses administered to surgical patients over age 65

BACKGROUND/OBJECTIVES

Advanced age is associated with increased susceptibility to acute adverse effects of propofol. The present study aimed to describe patterns of propofol dosing for induction of general anesthesia before endotracheal intubation in a nationwide sample of older adults presenting for surgery.

DESIGN

Retrospective observational study using the Multicenter Perioperative Outcomes Group data set.

SETTING

Thirty-six institutions across the United States.

PARTICIPANTS

A total of 350,766 patients aged over 65 years who received propofol for general anesthetic induction and endotracheal intubation between 2014 and 2018.

INTERVENTION

None.

MEASUREMENTS

Total induction bolus dose of propofol administered.

RESULTS

The mean (SD) weight-adjusted propofol dose was 1.7 (0.6) mg/kg. The mean prevalent propofol induction dose exceeded the upper bound of what has been described as the typical geriatric dose requirement across every age category examined. The percent of patients receiving propofol induction doses above the described typical geriatric range was 64.8% (95% CI 64.6-65.0), varying from 73.8% among patients aged 65-69 to 45.8% among patients aged 80 and older.

CONCLUSION

The present study of a large multicenter cohort demonstrates that prevalent propofol dosing commonly falls above the published typically required dose range for patients aged ≥65 in nationwide anesthetic practice. Widespread variability in induction dose administration remains incompletely explained by known patient variables. The nature and clinical consequences of these unexplained dosing decisions remain important topics for further study. Observed discordance between expected and actual induction dosing raises the question of whether there should be reconsideration of widespread provider practice or, alternatively, whether what is published as the typical propofol induction dose range should be revisited.

The Society for Obstetric Anesthesia and Perinatology Interdisciplinary Consensus Statement on Neuraxial Procedures in Obstetric Patients With Thrombocytopenia

Because up to 12% of obstetric patients meet criteria for the diagnosis of thrombocytopenia in pregnancy, it is not infrequent that the anesthesiologist must decide whether to proceed with a neuraxial procedure in an affected patient. Given the potential morbidity associated with general anesthesia for cesarean delivery, thoughtful consideration of which patients with thrombocytopenia are likely to have an increased risk of spinal epidural hematoma with neuraxial procedures, and when these risks outweigh the relative benefits is important to consider and to inform shared decision making with patients. Because there are substantial risks associated with withholding a neuraxial analgesic/anesthetic procedure in obstetric patients, every effort should be made to perform a bleeding history assessment and determine the thrombocytopenia etiology before admission for delivery. Whereas multiple other professional societies (obstetric, interventional pain, and hematologic) have published guidelines addressing platelet thresholds for safe neuraxial procedures, the US anesthesia professional societies have been silent on this topic. Despite a paucity of high-quality data, there are now meta-analyses that provide better estimations of risks. An interdisciplinary taskforce was convened to unite the relevant professional societies, synthesize the data, and provide a practical decision algorithm to help inform risk-benefit discussions and shared decision making with patients. Through a systematic review and modified Delphi process, the taskforce concluded that the best available evidence indicates the risk of spinal epidural hematoma associated with a platelet count ≥70,000 × 106/L is likely to be very low in obstetric patients with thrombocytopenia secondary to gestational thrombocytopenia, immune thrombocytopenia (ITP), and hypertensive disorders of pregnancy in the absence of other risk factors. Ultimately, the decision of whether to proceed with a neuraxial procedure in an obstetric patient with thrombocytopenia occurs within a clinical context. Potentially relevant factors include, but are not limited to, patient comorbidities, obstetric risk factors, airway examination, available airway equipment, risk of general anesthesia, and patient preference.

Application of etomidate and propofol mixture in hematoma removal in patients with intracranial epidural hematoma

OBJECTIVE

To innvestigate the application of etomidate and propofol mixture in the evacuation of hematoma in patients with epidural hematoma.

METHODS

98 patients with epidural hematoma were randomly divided into two groups: the joint group (n=49, anesthesia induction with etomidate and propofol) and the etomidate group (n=49, anesthesia induction with etomidate) using a random number table. Hemodynamics, stress response and cerebral oxygen metabolism were compared between the two groups at T0 (pre-anesthesia induction), T1 (after endotracheal intubation), T2 (10 min after the beginning of the operation) and T3 (the end of the operation). Adverse reactions were also analyzed.

RESULTS

Compared with T0, the mean arterial pressure (MAP) at T1, T2 and T3 in the joint group decreased first and then increased, and the MAP at T1 was significantly lower than that in the etomidate group (P<0.05). Compared with T0, blood oxygen saturation of internal jugular vein bulb (SjvO₂) increased in T1-T3 groups, and SjvO₂ in the joint group was higher than that in the etomidate group (all P<0.05). Compared with T0, cerebral oxygen uptake rate (CERO₂) in the T1-T3 groups decreased significantly, and CERO₂ at T3 in the joint group was higher than that in the etomidate group (all P<0.05). Compared with T0, the levels of cortisol and superoxide dismutase (SOD) at T3 in the two groups were significantly lower, but those in the etomidate group were higher than those in the combination group (all P<0.05). There was no significant difference in the incidence of postoperative anesthesia-related adverse reactions between the two groups (P>0.05).

CONCLUSION

Etomidate has less effect on hemodynamics and stress reaction during intravenous anesthesia, but its combination with propofol can improve cerebral oxygen metabolism to a certain extent with fewer adverse reactions.

Postoperative pain treatment with transmuscular quadratus lumborum block and fascia iliaca compartment block in patients undergoing total hip arthroplasty: a randomized controlled trial

Background

Patients often suffer moderate or even severe pain after total hip arthroplasty; such pain seriously affects early postoperative recovery. This study aimed to investigate the analgesic efficacy of ultrasound-guided transmuscular quadratus lumborum block combined with fascia iliaca compartment block for elderly patients undergoing total hip arthroplasty.

Methods

Fifty-four patients scheduled for total hip arthroplasty were included in this randomized controlled study. The patients were randomly assigned to receive only transmuscular quadratus lumborum block (group Q) or transmuscular quadratus lumborum block combined with fascia iliaca compartment block (group QF) with ultrasound guidance. Postoperatively in both groups, paracetamol 1 g was regularly administered at 6 h intervals and patient-controlled intravenous analgesia was administered. The primary outcome was cumulative sufentanil consumption via patient-controlled intravenous analgesia 24 h postoperatively. The secondary outcomes included pain degree, time to the first analgesic requirement, joint range of motion, quality of recovery, and the incidence of postoperative complications.

Results

Fifty patients were included, and their data were analyzed. The cumulative sufentanil consumption in group QF was significantly lower during the first 24 h after surgery than that in group Q, and the cumulative sufentanil consumption in group QF was reduced at 6–12 and 12–18 h after surgery. The postoperative pain intensity was lower in group QF than in group Q (linear mixed-effects model, the main effect of treatment: P < 0.001). Compared with group Q, group QF had higher quality of recovery and joint range of movement. The time to the first analgesic requirement was longer in group QF than in group Q (log-rank, P < 0.001). There was no statistically significant difference in complications postoperatively between the two groups.

Conclusions

Our study provides a multimodal, opioid-sparing analgesic regimen for elderly patients undergoing total hip arthroplasty. The combination of transmuscular quadratus lumborum block and fascia iliaca compartment block provides a significant advantage for early postoperative functional recovery. Further studies are required to confirm the minimum effective dose.

Trial registration

The study was registered on the 21st December 2020 (retrospectively registered) on the Chinese Clinical Trial Registry: ChiCTR2000038686.

Perioperative thrombocytopenia

PURPOSE OF REVIEW

In this review, we discuss recent developments and trends in the perioperative management of thrombocytopenia.

RECENT FINDINGS

Large contemporary data base studies show that preoperative thrombocytopenia is present in about 8% of asymptomatic patients, and is associated with increased risks for bleeding and 30-day mortality. Traditionally specific threshold platelet counts were recommended for specific procedures. However, the risk of bleeding may not correlate well with platelet counts and varies with platelet function depending on the underlying etiology. Evidence to support prophylactic platelet transfusion is limited and refractoriness to platelet transfusion is common. A number of options exist to optimize platelet counts prior to procedures, which include steroids, intravenous immunoglobulin, thrombopoietin receptor agonists, and monoclonal antibodies. In addition, intraoperative alternatives and adjuncts to transfusion should be considered. It appears reasonable to use prophylactic desmopressin and antifibrinolytic agents, whereas activated recombinant factor VII could be considered in severe bleeding. Other options include enhancing thrombin generation with prothrombin complex concentrate or increasing fibrinogen levels with fibrinogen concentrate or cryoprecipitate.

SUMMARY

Given the lack of good quality evidence, much research remains to be done. However, with a multidisciplinary multimodal perioperative strategy, the risk of bleeding can be decreased effectively.

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.

Associations of thrombocytopenia, transaminase elevations, and transfusion with laboratory coagulation tests in women with preeclampsia: a cross-sectional study

BACKGROUND

Women with preeclampsia may develop coagulopathy, predisposing to bleeding complications. Although guidelines and prior studies conflict, we hypothesized that in preeclampsia, abnormal coagulation test results are more common in women with thrombocytopenia or transaminase elevations and increase the transfusion risk. Our objectives were to investigate: 1. patterns of coagulation testing; 2. relationships between platelet count, transaminase level, and the risk of abnormal coagulation tests; 3. risk of bleeding complications; and 4. characteristics of patients with markedly abnormal coagulation parameters.

METHODS

We conducted a cross-sectional study of deliveries of women with preeclampsia who had undergone activated partial thromboplastin time (aPTT) or international normalized ratio (INR) testing at one of two hospitals between 1994 and 2018.

RESULTS

Of 10 699 women with preeclampsia, 3359 (32.7%) had coagulation testing performed and aPTT or INR elevations were present in 124 (3.7 %). Coagulation abnormalities were more common in women with thrombocytopenia or transaminase elevations (n=82) compared with those without (n=42) (6.7%, 95% CI 5.5 to 8.2 vs 1.8%, 95% CI 1.3 to 2.5). Transfusion was more common among women with abnormal coagulation parameters (n=124) compared with those without (n=39) (33.1 vs 7.0%, P <0.001). Among 26 patients with an aPTT ≥40 s or an INR ≥1.4, six required transfusion (all had placental abruption and disseminated intravascular coagulopathy).

CONCLUSIONS

Coagulation testing was inconsistently performed in this cohort. Platelet counts and transaminase levels inadequately detected abnormal coagulation test results. Abnormal coagulation test results were associated with a markedly higher risk for red blood cell transfusion.

Big Data in Studying Acute Pain and Regional Anesthesia

The digital transformation of healthcare is advancing, leading to an increasing availability of clinical data for research. Perioperative big data initiatives were established to monitor treatment quality and benchmark outcomes. However, big data analyses have long exceeded the status of pure quality surveillance instruments. Large retrospective studies nowadays often represent the first approach to new questions in clinical research and pave the way for more expensive and resource intensive prospective trials. As a consequence, the utilization of big data in acute pain and regional anesthesia research has considerably increased over the last decade. Multicentric clinical registries and administrative databases (e.g., healthcare claims databases) have collected millions of cases until today, on which basis several important research questions were approached. In acute pain research, big data was used to assess postoperative pain outcomes, opioid utilization, and the efficiency of multimodal pain management strategies. In regional anesthesia, adverse events and potential benefits of regional anesthesia on postoperative morbidity and mortality were evaluated. This article provides a narrative review on the growing importance of big data for research in acute postoperative pain and regional anesthesia.

Safety of fluoroscopically guided pain procedures in patients receiving cytotoxic chemotherapy: a retrospective analysis

PURPOSE

To examine the incidence of bleeding and infectious adverse events (AEs) in patients undergoing interventional, fluoroscopic-guided axial spine procedures to modulate pain.

METHODS

Retrospective data of patients undergoing fluoroscopically guided axial spine injections at a single tertiary care medical center Cancer Rehabilitation program in the USA were reviewed. AEs, type of chemotherapy, type of tumor, age, platelet and absolute neutrophil counts (ANC) prior to the procedure, and relevant past medical history were collected. Descriptive statistical analyses were performed.

RESULTS

Sixty-three separately identifiable procedures across 28 patients met inclusion criteria. Zero AEs were recorded. Platelet and ANC were generally above the recommended safety threshold, but granulocyte colony stimulating factor was administered prior to four procedures to boost ANC levels. Multiple myeloma was the most common cancer diagnosis (64.3%). Various solid tumors made up the remaining cancer diagnoses. Epidural steroid injections (n=23) and medial branch blocks (n=23) were the most common procedures performed and lumbar (n=35) was the most common location of procedures. Three patients died within 30 days of the procedures but their deaths were not directly attributable to the injections.

CONCLUSION

This provides preliminary data to support the safety of injections in patients receiving cytotoxic chemotherapy. Larger, multicenter studies are required before firm conclusions can be drawn.

Thromboelastography as a point-of-care guide for spinal anesthesia in an eclamptic patient: a case report

Neuraxial anesthesia is a standard of care during parturition. Since bleeding diathesis is a contraindication to neuraxial techniques, data about its safe administration in a thrombocytopenic milieu is limited and evolving. Thrombocytopenia associated with preeclampsia or eclampsia and hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome leads to significant maternal and neonatal morbidity. We present a case of uneventful spinal anesthesia for urgent cesarean section in an eclamptic patient with a precipitous drop in platelet count from 124,000 to 97,000 per cubic millimeter under thromboelastography (TEG) guidance.

Prevalence of aberrant blood pressure readings across two automated intraoperative blood pressure monitoring systems among patients undergoing caesarean delivery

OBJECTIVES

Aberrant automated blood pressure (BP) readings during caesarean delivery may lead to disruptions in monitoring. The present study compared the frequency of aberrant BP readings across two types of commercially available BP monitoring systems in use during caesarean delivery.

METHODS

This was a retrospective observational study using two comparable patient cohorts that resulted from simultaneous introduction of two types of monitors into a single obstetric surgical center in which similar patients were treated for the same surgical procedure by the same set of clinicians during the same year. Our primary hypothesis was that aberrant readings were significantly associated with the type of monitor being used for BP measurement, controlling for a variety of relevant covariates as specified in the analytic plan.

RESULTS

A total of 1418 cesarean delivery patients met inclusion criteria. Gaps of at least 6 min in machine-captured BP readings occurred in 159 (21.1%) of cases done in the operating room using a Datex-Ohmeda monitor vs. 183 (27.5%) of cases in the operating rooms using Phillips monitors (P = 0.005). In multivariable logistic regression analysis, the relative odds of the occurrence of monitoring gaps was 35% higher in rooms with the Phillips BP monitors as compared to the Datex-Ohmeda monitor while controlling for pre-specified covariates (odds ratio = 1.35, 95% confidence interval = 1.04-1.74, P = 0.02).

CONCLUSION

The present analysis suggests that aberrant BP readings for parturients undergoing caesarean delivery are significantly different between the two types of automated BP monitoring systems used in the operating rooms at our institution.

Pregnancy and COVID-19: pharmacologic considerations

In this review, we summarize evidence regarding the use of routine and investigational pharmacologic interventions for pregnant and lactating patients with coronavirus disease 2019 (COVID-19). Antenatal corticosteroids may be used routinely for fetal lung maturation between 24 and 34 weeks' gestation, but decisions in those with critical illness and those < 24 or > 34 weeks' gestation should be made on a case-by-case basis. Magnesium sulfate may be used for seizure prophylaxis and fetal neuroprotection, albeit cautiously in those with hypoxia and renal compromise. There are no contraindications to using low-dose aspirin to prevent placenta-mediated pregnancy complications when indicated. An algorithm for thromboprophylaxis in pregnant patients with COVID-19 is presented, which considers disease severity, timing of delivery in relation to disease onset, inpatient vs outpatient status, underlying comorbidities and contraindications to the use of anticoagulation. Nitrous oxide may be administered for labor analgesia while using appropriate personal protective equipment. Intravenous remifentanil patient-controlled analgesia should be used with caution in patients with respiratory depression. Liberal use of neuraxial labor analgesia may reduce the need for emergency general anesthesia which results in aerosolization. Short courses of non-steroidal anti-inflammatory drugs can be administered for postpartum analgesia, but opioids should be used with caution due to the risk of respiratory depression. For mechanically ventilated pregnant patients, neuromuscular blockade should be used for the shortest duration possible and reversal agents should be available on hand if delivery is imminent. To date, dexamethasone is the only proven and recommended experimental treatment for pregnant patients with COVID-19 who are mechanically ventilated or who require supplemental oxygen. Although hydroxycholoroquine, lopinavir/ritonavir and remdesivir may be used during pregnancy and lactation within the context of clinical trials, data from non-pregnant populations have not shown benefit. The role of monoclonal antibodies (tocilizumab), immunomodulators (tacrolimus), interferon, inhaled nitric oxide and convalescent plasma in pregnancy and lactation needs further evaluation. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Severe Thrombocytopenia in a Pregnant Patient with Asymptomatic COVID-19 Infection: A Case Report

Thrombocytopenia occurs in one-third of patients with coronavirus disease 2019 (COVID-19) infection and can indicate the severity of disease and may also increase the bleeding risk of performing invasive procedures. We present a pregnant patient with COVID-19 infection with the lowest platelet count described in the literature to date. The patient presented in labor at 38 weeks gestation with no other symptoms and was found to be positive on routine COVID-19 testing. The routine complete blood count upon admission was significant for a platelet count of 6 x 10⁹/L which was rechecked and resulted in a platelet count of 8 x 10⁹/L. The etiology of her thrombocytopenia was not clear prior to delivery as preeclampsia with severe features and lupus exacerbation were also possibilities that were considered. However, after delivery it became apparent that COVID-19 likely had a significant impact contributing to her severe thrombocytopenia. Her care was complicated by postpartum hemorrhage resulting in massive transfusion. This case highlights the importance of evaluating platelet count and coagulation status in COVID-19 patients, even if asymptomatic.

Budd-Chiari syndrome diagnosed with pregnancy in a patient with inherited thrombophilia

An 18-year-old primigravida was referred to our high risk pregnancy (HRP) department at 34 weeks of gestation for birth panning as she has Budd-Chiari syndrome (BCS). Her history was significant for familial thrombophilia. She had portal hypertension manifestations. Her work-up revealed factor V Leiden gene mutation, hepatic and portal vein thrombosis. A multidisciplinary team of physicians from the gastroenterology and hepatology, haematology and HRP departments puts a management plan; it culminated into safe delivery of the patient at 36 weeks of gestation. The patient was referred to a specialised BCS centre where she had successful liver transplantation done.

HOW Collaborative position paper on the management of thrombocytopenia in pregnancy

Thrombocytopenia in pregnancy is a common occurrence, affecting up to 10% of women by the time of birth. These recommendations aim to provide pragmatic guidance on the investigation, diagnosis and management of thrombocytopenia in pregnancy; including safety of neuraxial anaesthesia and precautions required for birth. Management of neonatal thrombocytopenia is also addressed. The authors are clinicians representing haematology, obstetric medicine, maternal-fetal medicine, and anaesthesia. Each author conducted a detailed literature review then worked collaboratively to produce a series of unanimous recommendations. The recommendation strength is limited by the lack of high-quality clinical trial data, and represents level C evidence.

Platelet storage pool disorder in pregnancy: Utilising thromboelastography to guide a risk-based delivery plan

We present a case of a 33-year-old woman in her third pregnancy diagnosed with platelet storage pool disorder who had previously suffered two postpartum major obstetric haemorrhages. Platelet storage pool disorder is a rare bleeding disorder where the platelet count is normal but platelet function is impaired due to deficiency of dense granules. A peripartum plan devised by an extensive multi-disciplinary team using principles for managing other bleeding and platelet function disorders helped minimise her risk of major haemorrhage. We also describe how point-of-care thromboelastography can help guide management and enable an individualised risk-benefit discussion with the woman about her anaesthetic choices.

Thromboelastometry-guided neuraxial anesthesia in a parturient with severe thrombocytopenia due to large granular lymphocytic leukemia

Severe thrombocytopenia (platelet count <50 000/μl) in pregnancy is uncommon and is generally considered a contraindication to neuraxial anesthesia. We present a case of a parturient who presented with severe thrombocytopenia secondary to bone marrow failure. After receiving platelet and cryoprecipitate transfusions to correct coagulopathy as verified by thromboelastometry, neuraxial anesthesia was safely utilized.