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BACKGROUND

  • Anticoagulation is a vital intervention to prevent venous thromboembolism and related maternal morbidity and mortality.

  • The use of anticoagulation in parturients is becoming increasingly more common and has a substantial impact on the use and timing of neuraxial anesthetic procedures.

  • As of yet, no professional society has published firm guidelines that adequately address the increased risk of epidural hematoma in anticoagulated obstetric patients. The American Society of Regional Anesthesia and Pain Medicine (ASRA) guidelines minimally differentiate between pregnant and nonpregnant patients and so do not account for the hypercoagulable state of pregnancy.1

  • In a recent systematic review, an analysis of 52 parturients whose anticoagulation was not held for the recommended period prior to a neuraxial procedure did not find a single documented incidence of spinal epidural hematoma.2

  • Using ASRA guidelines in an obstetric population would likely result in an inappropriate number of parturients being denied or delayed for neuraxial anesthesia, which leads to greater complications in those patients from the use of general anesthesia.

  • The following guideline for parturients on unfractionated heparin (UFH) regimens is based on both a consensus statement from the Society for Obstetric Anesthesia and Perinatology,3 related ASRA guidelines, and the experience of our senior staff.

  • Establishing good communication with the patient, the obstetric team, and the nursing staff during both the antepartum period and upon the patient’s arrival to the labor and delivery unit is essential and will aid in the adequate delivery of appropriate anesthetic care for labor analgesia in this patient population.

ANTEPARTUM

  • Every patient on anticoagulation should receive an obstetric anesthesia consult appointment to discuss anesthetic options and the appropriate timing of neuraxial interventions in the setting of anticoagulation.

  • We recommend all patients on low-molecular-weight heparin, such as enoxaparin, transition to UFH at 36 weeks, when possible. This allows for a more liberal timetable for neuraxial anesthesia should labor commence prior to the patient’s due date.

Patients are advised not to administer any scheduled dose of UFH prior to arrival at the hospital if they are concerned that they may be going into labor.

PRIOR TO DELIVERY

Assess the patient’s anticoagulation regimen, renal function, and bleeding history, and proceed as shown in Fig. 17-1.

FIGURE 17-1

Decision aid for neuraxial procedure in parturients on anticogulants. aPTT, activated partial thromboplastin time; GA, general anesthesia; Hx, history; SEH, subarachnoid or epidural hematoma; SQ, subcutaneous; UFH, unfractionated heparin.

OTHER CONSIDERATIONS

  • For patients on enoxaparin, adhere to the ASRA guidelines for the timing of neuraxial as there is insufficient data currently to change this practice.

  • For patients on heparin for >4 days, a platelet count should be performed within the past 24 hours prior to neuraxial procedures due to the risk of heparin-induced thrombocytopenia.

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