Thromboprophylaxis and neuroaxial anaesthesia in obstetrics

Czech version

Authors: Bláha Jan ¹; Nosková Pavlína ¹; Kolníková Ivana ¹; Bláhová Kateřina ²
Authors‘ workplace: Klinika anesteziologie, resuscitace a intenzivní medicíny 1. LF UK a VFN v Praze ¹; Gynekologicko-porodnická klinika VFN v Praze ²
Published in: Anest. intenziv. Med., 23, 2012, č. 1, s. 42-49
Category: Anesthesiology - Review Article

Overview

Spinal hematoma (SH) after neuraxial puncture is considered the most serious complication of regional anaesthesia. The risk is further significantly increased by co-administration of thromboprophylaxis with low molecular weight heparins (LMWH). In the 1990s, the risk of SH on the basis of published case reports was estimated as 1 : 1 000 000. These estimates are now closer to 1 : 3 000. Concomitant application of LMWH is responsible for such a dramatic increase of the risk of SH, especially in orthopaedics. Therefore, a number of anaesthesiology societies have adopted a recommendation concerning the time relation between the administration of neuraxial anaesthesia and LMWH applications. Generally, the risks are only approximated for the low incidence of SH, and for pregnant women this risk is estimated between 1 : 200 000 and 1 : 400 000. If there is an increased risk of SH with concomitant LMWH in orthopaedic patients, in the case of obstetric anaesthesia this increased risk is very questionable. So far there has not been a single published case report giving the context of SH and LMWH use in pregnancy, which, in addition to the physiological hypercoagulable state, differs in altered pharmacokinetics and pharmacodynamics of LMWH. The following text attempts to summarize the current information available regarding the relation of thromboprophylaxis and the risk of spinal hematoma in obstetrics.

Keywords:
LMWH – thromboprophylaxis – regional anaesthesia – spinal haematoma – pregnancy

Sources

1. Rahman, K., Jenkins, J. G. Failed tracheal intubation in obstetrics: no more frequent but still managed badly. Anaesthesia, 2005, 60, 2, p. 168–171.

2. McDonnell, N. J., Paech, M. J., Clavisi, O. M., Scott, K. L. Difficult and failed intubation in obstetric anaesthesia: an observational study of airway management and complications associated with general anaesthesia for caesarean section. Int. J. Obstet. Anesth., 2009, 17, 4, p. 292–297.

3. Lyons, G., Akerman, N. Problems with general anaesthesia for Caesarean section. Minerva Anestesiol., 2005, 71, 1–2, p. 27–38.

4. Barnardo, P. D., Jenkins, J. G. Failed tracheal intubation in obstetrics: a 6-year review in a UK region. Anaesthesia, 2000, 55, 7, p. 690–694.

5. Lyons, G. Saving mothers’ lives: confidential enquiry into maternal and child health 2003–5. Int. J. Obstet. Anesth., 2008, 17, 2, p. 103–105.

6. James, A. H. Prevention and management of venous thromboembolism in pregnancy. Am. J. Med., 2007, 120, 10 Suppl 2, S26–34.

7. Kujovich, J. L. Hormones and pregnancy: thromboembolic risks for women. Br. J. Haematol., 2004, 126, 4, p. 443–454.

8. James, A. H. Pregnancy and thrombotic risk. Crit. Care Med., 2010, 38, 2, Suppl, S57–63.

9. Bremme, K. A. Haemostatic changes in pregnancy. Best Pract. Res. Clin. Haematol., 2003, 16, 2, p. 153–168.

10. Roeters van Lennep, J. E., Meijer, E., Klumper, F. J., Middeldorp, J. M., Bloemenkamp, K. W., Middeldorp, S. Prophylaxis with low-dose low-molecular-weight heparin during pregnancy and postpartum: is it effective? Journal of Thrombosis and Haemostasis, 2011, 9, 3, p. 473–480.

11. Heit, J. A., Kobbervig, C. E., James, A. H., Petterson, T. M., Bailey, K. R., Melton, L. J. 3rd: Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. Annals Inter. Med., 2005, 143, 10, p. 697–706.

12. James, A. H., Jamison, M. G., Brancazio, L. R., Myers, E. R. Venous thromboembolism during pregnancy and the postpartum period: incidence, risk factors, and mortality. Am. J. Obstet. Gynec., 2006, 194, 5, p. 1311–1315.

13. James, A. H. Pregnancy-associated thrombosis. Hematology Am. Soc. Hematol. Educ. Program, 2009, p. 277–285.

14. Rosenberg, V. A., Lockwood, C. J. Thromboembolism in pregnancy. Obstet. Gynec. Clin. North America, 2007, 34, 3, p. 481–500.

15. Widimský, J., Malý, J., Eliáš, P., Lang, O., Franc, P., Roztočil, K. Doporučení diagnostiky, léčby a prevence plicní embolie. Vnitr. Lek., 2008, 54, Suppl 1, S25–S72.

16. Horlocker, T. T., Wedel, D. J., Rowlingson, J. C., Enneking, F. K., Kopp, S. L., Benzon, H. T., Brown, D. L., Heit, J. A., Mulroy, M. F., Rosenquist, R. W. et al. 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, 1, p. 64–101.

17. Marik, P. E. Venous thromboembolism in pregnancy. Clinics in Chest Medicine, 2010, 31, 4, p. 731–740.

18. Bates, S. M., Greer, I. A., Hirsh, J., Ginsberg, J. S. Use of antithrombotic agents during pregnancy: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest, 2004, 126, 3, Suppl, p. 627S–644S.

19. Patel, J. P., Patel, R. K., Davies, J. G., Arya, R. Prophylaxis with low-dose low molecular weight heparin during pregnancy and the puerperium: is it effective? A rebuttal. Journal of Thrombosis and Haemostasis, 2011, 9, 6, p. 1269–1271; author reply 1272-1263.

20. Patel, J. P., Hunt, B. J. Where do we go now with low molecular weight heparin use in obstetric care? Journal of Thrombosis and Haemostasis, 2008, 6, 9, p. 1461–1467.

21. Herold, I. Antikoagulační terapie a neuroaxiální analgezie/anestezie. In Pařízek A. Porodnická anestezie a analgezie. Praha: Grada 2002.

22. Beards, S. C., Jackson, A., Griffiths, A. G., Horsman, E. L. Magnetic resonance imaging of extradural blood patches: appearances from 30 min to 18 h. Brit. J. Anaesth., 1993, 71, 2, p. 182–188.

23. Moen, V., Dahlgren, N., Irestedt, L. Severe neurological complications after central neuraxial blockades in Sweden 1990–1999. Anesthesiology, 2004, 101, 4, p. 950–959.

24. Checketts, M. R., Wildsmith, J. A. Central nerve block and thromboprophylaxis – is there a problem? Brit. J. Anaesth., 1999, 82, 2, p. 164–167.

25. Checketts, M. R., Wildsmith, J. A. Epidural haematoma following anticoagulant treatment in a patient with an indwelling epidural catheter. Anaesthesia, 1999, 54, 1, p. 87–88.

26. Vandermeulen, E. P., Van Aken, H., Vermylen, J. Anticoagulants and spinal-epidural anesthesia. Anesth. Analg., 1994, 79, 6, p. 1165–1177.

27. Jacob, A. K., Borowiec, J. C., Long, T. R., Brown, M. J., Rydberg, C. H., Wass, C. T. Transient profound neurologic deficit associated with thoracic epidural analgesia in an elderly patient. Anesthesiology, 2004, 101, 6, p. 1470–1471.

28. Scott, D. B., Tunstall, M. E. Serious complications associated with epidural/spinal blockade in obstetrics: a two-year prospective study. Int. J. Obst. Anesth., 1995, 4, 3, p. 133–139.

29. Palot, M., Visseaux, H., Botmans, C., Pire, J. C. [Epidemiology of complications of obstetrical epidural analgesia]. Cah. Anesthesiol., 1994, 42, 2, p. 229–233.

30. Paech, M. J., Godkin, R., Webster, S. Complications of obstetric epidural analgesia and anaesthesia: a prospective analysis of 10,995 cases. Int. J. Obst. Anesth., 1998, 7, 1, p. 5–11.

31. Loo, C. C., Dahlgren, G., Irestedt, L. Neurological complications in obstetric regional anaesthesia. Int. J. Obst. Anesth., 2000, 9, 2, p. 99–124.

32. Bose, S., Ali, Z., Rath, G. P., Prabhakar, H. Spontaneous spinal epidural haematoma: a rare cause of quadriplegia in the post-partum period. Brit. J. Anaesth., 2007, 99, 6, p. 855–857.

33. Tryba, M., Wedel, D. J. Central neuraxial block and low molecular weight heparin (enoxaparine): lessons learned from different dosage regimes in two continents. Acta Anaesth. Scan. Supplementum, 1997, 111, p. 100–104.

34. Horlocker, T. T., Wedel, D. J. Neuraxial block and low-molecular-weight heparin: balancing perioperative analgesia and thromboprophylaxis. Reg. Anesth. Pain Med., 1998, 23, 6, Suppl 2, p. 164–177.

35. Horlocker, T. T., Wedel, D. J. Anticoagulation and neuraxial block: historical perspective, anesthetic implications, and risk management. Reg. Anesth. Pain Med., 1998, 23, 6, Suppl 2, p. 129–134.

36. Tryba, M. European practice guidelines: thromboembolism prophylaxis and regional anesthesia. Reg. Anesth. Pain Med., 1998, 23, 6, Suppl 2, p. 178–182.

37. Schroeder, D. R. Statistics: detecting a rare adverse drug reaction using spontaneous reports. Reg. Anesth. Pain Med., 1998, 23, 6, Suppl 2, p. 183–189.

38. Cameron, C. M., Scott, D. A., McDonald, W. M., Davies, M. J. A review of neuraxial epidural morbidity: experience of more than 8,000 cases at a single teaching hospital. Anesthesiology, 2007, 106, 5, p. 997–1002.

39. Christie, I. W., McCabe, S. Major complications of epidural analgesia after surgery: results of a six-year survey. Anaesthesia, 2007, 62, 4, p. 335–341.

40. Popping, D. M., Zahn, P. K., Van Aken, H. K., Dasch, B., Boche, R., Pogatzki-Zahn, E. M. Effectiveness and safety of postoperative pain management: a survey of 18 925 consecutive patients between 1998 and 2006 (2nd revision): a database analysis of prospectively raised data. Brit. J. Anaesth., 2008, 101, 6, p. 832–840.

41. Cook, T. M., Counsell, D., Wildsmith, J. A. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. Brit. J. Anaesth., 2009, 102, 2, p. 179–190.

42. Gogarten, W., Van Aken, H., Wulf, H., Klose, R., Vandermeulen, E., Harenberg, J. Rückenmarksnahe Regionalanästhesien und Thromboemboliepropyhlaxe/Antikoagulation. Anaesth. Intensivmed., 1997, 38, 3, p. 623–628.

43. Belgian guidelines concerning drug induced alteration of coagulation and central neuraxial anesthesia. Belgian Society for Anesthesia and Resuscitation. Acta Anaesth. Belgica, 2000, 51, 2, p. 101–104.

44. CLEXANE INJ SOL 2X0.4ML/4KU, dostupné na [http: //www.sukl.cz/modules/medication/detail.php?kod=0115406]

45. Green, L., Machin, S. J. Managing anticoagulated patients during neuraxial anaesthesia. Br. J. Haematol., 2010, 149, 2, p. 195–208.

46. Vandermeulen, E., Singelyn, F., Vercauteren, M., Brichant, J. F., Ickx, B. E., Gautier, P. Belgian guidelines concerning central neural blockade in patients with drug-induced alteration of coagulation: an update. Acta Anaesth. Belgica, 2005, 56, 2, p. 139–146.

47. Chestnut, D. H. (ed.) Obstetric Anesthesia: Principles and Practice. 4 edn. Philadelphia: Mosby, Elsevier Inc. 2009.

48. Breivik, H., Bang, U., Jalonen, J., Vigfusson, G., Alahuhta, S., Lagerkranser, M. Nordic guidelines for neuraxial blocks in disturbed haemostasis from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesth. Scand., 2010, 54, 1, p. 16–41.

49. Moen, V. Scandinavian guidelines for neuraxial block and disturbed haemostasis: replacing wishful thinking with evidence based caution. Acta Anaesth. Scand., 2010, 54, 1, p. 6–8.

50. Gogarten, W., Vandermeulen, E., Van Aken, H., Kozek, S., Llau, J. V., Samama, C. M. Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. Europ. J. Anaesth., 2010, 27, 12, p. 999–1015.

51. Kozek-Langenecker, S. A., Fries, D., Gutl, M., Hofmann, N., Innerhofer, P., Kneifl, W., Neuner, L., Perger, P., Pernerstorfer, T., Pfanner, G. et al. [Locoregional anesthesia and coagulation inhibitors. Recommendations of the Task Force on Perioperative Coagulation of the Austrian Society for Anesthesiology and Intensive Care Medicine]. Der Anaesthesist, 2005, 54, 5, p. 476–484.

52. [Clinical guidelines for inhibitors of hemostasis and locoregional neuraxial anesthesia. Spanish Society of Anesthesiology-Resuscitation and Pain Therapy, Division of Hemostasis, Transfusion Medicine, and Perioperative Fluid Therapy]. Revista espanola de anestesiologia y reanimacion, 2005, 52, 7, p. 413–420.

53. Neuraxisblokkade en antistolling, dostupné na www: [http: //www.anesthesiologie.nl/uploads/118/29/Richtlijn_antistolling_DEF.pdf]

54. Les blocs périmédullaires chez l’adulte. Recommandations pour la pratique clinique. 2006.

55. Ruppen, W., Derry, S., McQuay, H., Moore, R. A. Incidence of epidural hematoma, infection, and neurologic injury in obstetric patients with epidural analgesia/anesthesia. Anesthesiology, 2006, 105, 2, p. 394–399.

56. Lebaudy, C., Hulot, J. S., Amoura, Z., Costedoat-Chalumeau, N., Serreau, R., Ankri, A., Conard, J., Cornet, A., Dommergues, M., Piette, J. C. et al. Changes in enoxaparin pharmacokinetics during pregnancy and implications for antithrombotic therapeutic strategy. Clin. Pharm. Ther., 2008, 84, 3, p. 370–377.

57. Sephton, V., Farquharson, R. G., Topping, J., Quenby, S. M., Cowan, C., Back, D. J., Toh, C. H. A longitudinal study of maternal dose response to low molecular weight heparin in pregnancy. Obst. Gynec., 2003, 101, 6, p. 1307–1311.

58. Anderson, G. D. Pregnancy-induced changes in pharmacokinetics: a mechanistic-based approach. Clin. Pharmacokinetics, 2005, 44, 10, p. 989–1008.

59. Bates, S. M., Greer, I. A., Pabinger, I., Sofaer, S., Hirsh, J. Venous thromboembolism, thrombophilia, antithrombotic therapy, and pregnancy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest, 2008, 133, 6, Suppl, p. 844S–886S.

60. Kaiser, P., Harenberg, J., Walenga, J. M., Huhle, G., Giese, C., Prechel, M., Hoppensteadt, D., Fareed, J. Effects of a heparin-binding protein on blood coagulation and platelet function. Seminars in thrombosis and hemostasis, 2001, 27, 5, p. 495–502.

61. Stock, S. J., Walker, M. C., Edelshain, B. T., Horn, L., Norman, J. E., Denison, F. C. Fixed dosing regimes of enoxaparin for thromboprophylaxis do not reliably achieve target anti-Xa levels in women of normal weight during pregnancy. European journal of obstetrics, gynecology, and reproductive biology 2011, 158, 1, p. 112–113.

62. Fox, N. S., Laughon, S. K., Bender, S. D., Saltzman, D. H., Rebarber, A. Anti-factor Xa plasma levels in pregnant women receiving low molecular weight heparin thromboprophylaxis. Obst. Gynecol., 2008, 112, 4, p. 884–889.

63. Yoneda, M., Brosnan, J. F., Norris, L. A., Bonnar, J. The effect of LMWH (tinzaparin) on coagulation and fibrinolytic activation in pregnant women at risk of thrombosis. Thrombosis research, 2006, 117, 3, p. 283–290.

64. Shapiro, N. L., Kominiarek, M. A., Nutescu, E. A., Chevalier, A. B., Hibbard, J. U. Dosing and monitoring of low-molecular-weight heparin in high-risk pregnancy: single-center experience. Pharmacotherapy, 2011, 31, 7, p. 678–685.

65. Butwick, A. J., Carvalho, B. Neuraxial anesthesia in obstetric patients receiving anticoagulant and antithrombotic drugs. Inter. J. Obstet. Anesth., 2010, 19, 2, p. 193–201.

66. Norris, L. A., Bonnar, J., Smith, M. P., Steer, P. J., Savidge, G. Low molecular weight heparin (tinzaparin) therapy for moderate risk thromboprophylaxis during pregnancy. A pharmacokinetic study. Thromb. Haemost., 2004, 92, 4, p. 791–796.

67. Liu, S. S., Mulroy, M. F. Neuraxial anesthesia and analgesia in the presence of standard heparin. Reg. Anesth. Pain Med., 1998, 23, 6, Suppl 2, p. 157–163.

68. Millar, F. A., Mackenzie, A., Hutchison, G., Bannister, J. Hemostasis-altering drugs and central neural block. A survey of anesthetic practice in Scotland and the United Kingdom. Regional anesthesia 1996, 21(6):529-533.

69. Rodgers, A., Sage, D., Futter, M., MacMahon, S. Attitudes and practices of New Zealand anaesthetists with regard to epidural and subarachnoid anaesthesia. Anaesth. Inten. Care, 1996, 24, 1, p. 79–86.

70. Hull, R. D., Pineo, G. F., MacIsaac, S. Low-molecular-weight heparin prophylaxis: preoperative versus postoperative initiation in patients undergoing elective hip surgery. Thrombosis Research, 2001, 101, 1, V155–162.

71. Strebel, N., Prins, M., Agnelli, G., Buller, H. R. Preoperative or postoperative start of prophylaxis for venous thromboembolism with low-molecular-weight heparin in elective hip surgery? Arch. Int. Med., 2002, 162, 13, p. 1451–1456.

72. Geerts, W. H., Bergqvist, D., Pineo, G. F., Heit, J. A., Samama, C. M., Lassen, M. R., Colwell, C. W. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest, 2008, 133, 6 Suppl, 381S–453S.

73. Huo, M. H., Spyropoulos, A. C. The eighth American college of chest physicians guidelines on venous thromboembolism prevention: implications for hospital prophylaxis strategies. J. Thromb. Thrombolysis, 2011, 31, 2, p. 196–208.

74. AWMF-Leitlinie Prophylaxe der venösen Thromboembolie (VTE) [http://www.awmf.org/leitlinien/detail/ll/003-001.html]

75. Sia, W. W., Powrie, R. O., Cooper, A. B., Larson, L., Phipps, M., Spencer, P., Sauve, N., Rosene-Montella, K. The incidence of deep vein thrombosis in women undergoing cesarean delivery. Thromb. Research, 2009, 123, 3, p. 550–555.

76. RCOG: Thrombosis and Embolism during Pregnancy and the Puerperium, Reducing the Risk. (Green-top 37a), 2009.

77. Horlocker, T. T., Wedel, D. J., Benzon, H., Brown, D. L., Enneking, F. K., Heit, J. A., Mulroy, M. F., Rosenquist, R. W., Rowlingson, J., Tryba, M. et al. Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg. Anesth. Pain Med., 2003, 28, 3, p. 172–197.

78. Horlocker, T. T. Thromboprophylaxis and neuraxial anesthesia. Orthopedics, 2003, 26, 2 Suppl, p. 243–249.

Labels

Anaesthesiology, Resuscitation and Inten Intensive Care Medicine

Use of neuromuscular blocking agents in general anaesthesia for surgery: A three-month, single-centre study in a Czech regional hospital

Kardiorelax 2011 – a five-day observational study of neuromuscular blockade during adult cardiac surgery in the Czech Republic

Influence of age and gender on the pharmacodynamic parameters of rocuronium during total intravenous anaesthesia – a prospective study

Quality of epidural analgesia and incidence of early complications after major surgery

Propofol vs. sevoflurane as anaesthetic maintenance agents in patients undergoing brain aneurysm coiling – randomized prospective study

Article was published in

Anaesthesiology and Intensive Care Medicine

2012 Issue 1