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Pregnant Patients on Anticoagulants

  • Sunanda Gupta
  • Anju Grewal
Chapter

Abstract

The main goal in parturients receiving anticoagulation and neuraxial anesthesia is to balance the risks of spinal epidural hematoma (SEH) versus benefits of neuraxial techniques for safer maternal and fetal outcomes. An understanding of the unique pregnancy associated physiological pharmacokinetic and pharmacodynamic changes, along with advanced patient centric planning as part of multidisciplinary team approach requires vigilant deliberation.

Prevention of SEH entails adherence to current guidelines for timing neuraxial block insertion/catheter removal with the last or subsequent dose of anticoagulant, along with use of dilute solutions of local anesthetics. Vigilant monitoring is essential to detect early neurological symptoms which may thwart progression to permanent sequelae.

Keywords

Neuraxial analgesia/anesthesia Anticoagulation Pregnancy Spinal epidural hematoma 

References

  1. 1.
    Butwick AJ, Carvalho B. Neuraxial anesthesia in obstetric patients receiving anticoagulants and antithrombotic drugs. Int J Obstet Anesth. 2010;19:193–201.CrossRefGoogle Scholar
  2. 2.
    Butwick AJ, Carvalho B. Anticoagulant and antithrombotic drugs in pregnancy: what are the anesthetic implications for labor and cesarean delivery? J Perinatol. 2011;31:73–84.CrossRefGoogle Scholar
  3. 3.
    Vandermeulen E. Regional anaesthesia and anticoagulation. Best Pract Res Clin Anaesthesiol. 2010;24:121–31.CrossRefGoogle Scholar
  4. 4.
    Leffert L, Butwick A, Carvalho B, et al. The Soicety for Obstetric Anesthesia and Perinatalogy concensus statement on the anesthetic management of pregnant and postpartum women receiving thromboprophylaxis or higher dose anticoagulants. Anesth Analg. 2017;126:928–44.  https://doi.org/10.1213/ANE0000000000002530.CrossRefGoogle Scholar
  5. 5.
    Gonzalez-Fiol A, Eisenberger A. Anesthesia implications of coagulation and anticoagulation during pregnancy. Semin Perinatol. 2014;38:370–7.CrossRefGoogle Scholar
  6. 6.
    Nishimura RA, Warnes CA. Anticoagulation during pregnancy in women with prosthetic valves: evidence, guidelines and unanswered questions. Heart. 2015;0:1–6.  https://doi.org/10.1136/heartjnl-2014-306500.CrossRefGoogle Scholar
  7. 7.
    Forsnes E, Occhino A, Acosta R. Spontaneousspinal epidural hematoma in pregnancy associated with using low molecular weight heparin. Obstet Gynecol. 2009;113:532–3.CrossRefGoogle Scholar
  8. 8.
    D’Angelo R, Smiley RM, Riley ET, Segal S. Serious complications related to obstetric anesthesia: the serious complication repository project of the Society for Obstetric Anesthesia and Perinatology. Anesthesiology. 2014;120:1505–12.CrossRefGoogle Scholar
  9. 9.
    Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden 1990–1999. Anesthesiology. 2004;101:950–9.CrossRefGoogle Scholar
  10. 10.
    Popping DM, Zahn PK, Van Aken HK, Dasch B, Boche R, Pogatzki-Zahn EM. 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. Br J Anaesth. 2008;101:832–40.CrossRefGoogle Scholar
  11. 11.
    Bateman BT, Mhyre JM, Ehrenfeld J, et al. The risk and outcomes of epidural hematomas after perioperative and obstetric epidural catheterization: a report from the Multicenter Perioperative Outcomes Group Research Consortium. Anesth Analg. 2013;116:1380–5.CrossRefGoogle Scholar
  12. 12.
    Leffert LR, Dubois HM, Butwick AJ, Carvalho B, Houle TT, Landau R. Neuraxial anesthesia in obstetric patients receiving thromboprophylaxis with unfractionated or low-molecular-weight heparin: a systematic review of spinal epidural hematoma. Anesth Analg. 2017;125(1):223–31.  https://doi.org/10.1213/ANE.0000000000002173.CrossRefPubMedGoogle Scholar
  13. 13.
    Ansari J, Carvalho B, Shafer SL, Flood P. Pharmacokinetics and pharmacodynamics of drugs commonly used in pregnancy and parturition. Anesth Analg. 2016;122:786–804.CrossRefGoogle Scholar
  14. 14.
    Horlocker TT, Wedel DJ, Rowlingson JC, Kayser Enneking F, Kopp SL, Benzon HT, et al. Regional anesthesia in the patient receiving antithromboticor thrombolytic therapy. American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010;35(1):64–101.CrossRefGoogle Scholar
  15. 15.
    Gogarten W, Vandermeulen E, Van Aken H, Kozek S, Llau JV, Samama CM. Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. Eur J Anaesthesiol. 2010;27:999–1015.CrossRefGoogle Scholar
  16. 16.
    Bates SM, Greer IA, 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;133:844S–86S.CrossRefGoogle Scholar
  17. 17.
    Rosencher N, Bonnet MP, Sessler DI. Anaesthesia and antithrombotic agents. Anaesthesia. 2007;62:1154–60.CrossRefGoogle Scholar
  18. 18.
    Horlocker TT. Regional anaesthesia in the patient receiving antithrombotic and antiplatelet therapy. Br J Anaesth. 2011;107(51):i96–i106.CrossRefGoogle Scholar
  19. 19.
    Green L, Machin SJ. Managing anticoagulated patients during neuraxial anaesthesia. Br J Haematol. 2010;149:195–208.CrossRefGoogle Scholar
  20. 20.
    Oprea AD, Noto CJ, Halaszynski TM. Risk stratification, perioperative and periprocedural management of the patient receiving anticoagulant therapy. J Clin Anesth. 2016;34:586–99.CrossRefGoogle Scholar
  21. 21.
    Harrop-Griffiths W, Cook T, Gill H, Hill D, Ingram M, Makris M, Malhotra S, Nicholls B, Popat M, Swales H, Wood P. Regional anaesthesia and patients with abnormalities of coagulation. Anaesthesia. 2013;68:966–72.  https://doi.org/10.1111/anae.12359.CrossRefGoogle Scholar
  22. 22.
    Butwick A, Hass C, Wong J, Lyell D, El-Sayed Y. Anticoagulant prescribing practices and anesthetic intervention among anticoagulated pregnant patients: a retrospective study. Int J Obstet Anesth. 2014;23:238–45.CrossRefGoogle Scholar
  23. 23.
    American College of Obstetricians and Gynecologists Womens Healthcare Physicians. ACOG practice bulletin No. 138: inherited thrombophilias in pregnancy. Obstet Gynecol. 2013;122:706–16.CrossRefGoogle Scholar
  24. 24.
    Benzon HT, Avram MJ, Green D, Bonow RO. Newer anticoagulants and regional anesthesia. Br J Anaesth. 2013;11(S1):i96–i113.  https://doi.org/10.1093/bja/aet401.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Sunanda Gupta
    • 1
  • Anju Grewal
    • 2
  1. 1.Department of Anaesthesiology and Critical CareGeetanjali Medical College and HospitalUdaipurIndia
  2. 2.Department of AnaesthesiologyDayanand Medical College and HospitalLudhianaIndia

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