The Possibilities of Thromboelastography in Assessing Safety of Neuraxial Blocks in Gestational Thrombocytopenia (Clinical Study)

Gestational thrombocytopenia (GT) is the most common type of thrombocytopenia during pregnancy. Unlike other types of thrombocytopenia, it is not accompanied by dysfunction of the cellular component of hemostasis. Currently, a quantitative decrease in platelets in GT is a contraindication to neuraxial blockades (NAB), which significantly reduces the quality of care in childbirth.

The aim of the study is to determine the possibility of safe use of neuraxial blockades in gestational thrombocytopenia. A retrospective prospective study involved 70 patients who were performed delivery, depending on obstetric indications, either conservatively or surgically. The patients were divided into two groups. The main group (group No. 1) included 35 patients with gestational thrombocytopenia. The comparison group (group No. 2) consisted of 35 patients with a platelet content above 150×10⁹/l. A comparative intergroup analysis of indicators of a general blood test, coagulogram, thromboelastography with a test for functional fibrinogen before childbirth and 2 days after delivery. The change in platelet content and its effect on the coagulation status of patients during pregnancy were retrospectively analyzed. A comparative assessment of the volume of blood loss during childbirth and the early postpartum period and the risk of complications of neuraxial blockade in patients with and without gestational thrombocytopenia was carried out.

It was found that during gestational thrombocytopenia in the perinatal period, there is no decrease in coagulation potential, assessed by the results of coagulography and thromboelastography at a platelet level above 49×10⁹/l. The investigated indicators of hemostasis did not have significant intergroup differences during pregnancy and childbirth. In the group of patients with gestational thrombocytopenia, the volume of blood loss during labor and the postpartum period did not differ from the group without thrombocytopenia, regardless of the method of delivery. The median blood loss after vaginal delivery in group 1 was 225 ml, in group 2 – 250 ml, with abdominal delivery – 572 ml and 386 ml – respectively. In this study, no complications of neuraxial blockade were observed in any of the groups.

The results obtained suggest that in patients with gestational thrombocytopenia, even with a significant decrease in platelet content, it is possible to perform neuraxial blockades during labor, taking into account the clinical picture and the absence of coagulation disorders confirmed by thromboelastography.

1. Cines DB, Levine LD. Thrombocytopenia in pregnancy. Blood. 2017;131(21):2271–2277. https://doi.org/10.1182/blood-2017-05-781971. PMID: 28637667

2. Umazume T, Yamada T, Morikawa M, Ishikawa S, Furuta I, Koyama T, et al. Platelet reactivity in twin pregnancies. Thromb Res. 2016;138:43–48. PMID: 26826507 https://doi.org/10.1016/j.thromres.2015.12.019

3. Kasai J, Aoki S, Kamiya N, Hasegawa Y, Kurasawa K, Takahashi T, et al. Clinical features of gestational thrombocytopenia difficult to differentiate from immune thrombocytopenia diagnosed during pregnancy. J Obstet Gynaecol. 2014;41(1):44–49. PMID: 25163390 https://doi.org/10.1111/jog.12496

4. Asif N, Hassan K. Thrombocytopenia in Pregnancy. Hematol Transfus Int J. 2017;5(5):307–309. https://doi.org/10.15406/htij.2017.05.00133

5. Fogerty A.E. Thrombocytopenia in pregnancy: mechanisms and management. Transfus Med Rev. 2018;32(4):225–229. PMID: 30177431 https://doi.org/10.1016/j.tmrv.2018.08.004

6. Grandone E, Mingalimov MA, Grigoryeva KN, Bitsadze VO, Shkoda AS, Khizroeva DKh, et al. Thrombocytopenic syndromes during pregnancy. Obstetrics and gynecology. 2019;10:5–12. (in Russ.). https://doi.org/10.18565/aig.2019.10.5-12

7. Palta A, Dhiman P. Thrombocytopenia in pregnancy. J Obstet Gynaecol. 2016;36(2):146–52. PMID: 26431056. https://doi.org/10.3109/01443615.2015.1041893

8. Kulikova AV, Shifman EM, Sokologorskiy SV, Levit AL, Nedashkovskiy EV, Zabolotskikh IB, et al. Neyroaksial’nye metody obezbolivaniya rodov. Klinichekie rekomendatsii. Protokoly lecheniya. In: Kulikov AV, Shifman EM (eds.). Anesteziologiya, intensivnaya terapiya i reanimatsiya v akusherstve i ginekologii. Klinicheskie rekomendatsii. Protokoly lecheniya. Moscow: Meditsina Publ.; 2017:153–169. (in Russ.) https://doi.org/10.18821/9785225100384

9. Lagerkranser M. Review Neuraxial blocks and spinal haematoma: Review of 166 case re-portspublished 1994–2015. Part 1: Demographics and risk-factors. Scand J Pain. 2017;15:118–129. PMID: 28850335 https://doi.org/10.1016/j.sjpain.2016.11.008

10. Lagerkranser M., Lindquist Сh. Neuraxial blocks and spinal haematoma: Review of 166 cas-espublished 1994–2015. Part 2: diagnosis, treatment, and outcome. Scand J Pain. 2017;15(1):130–136. PMID: 28850336 https://doi.org/10.1016/j.sjpain.2016.11.009

11. Bateman BT, Mhyre JM, Ehrenfeld J, Kheterpal S, Abbey KR, Argalious M, et al. The Risk and Outcomes of Epidural Hematomas After Perioperative and Obstetric Epidural Catheterization: A Report from the Multicenter Perioperative. Anesth Analg. 2013;116(6):1380–1385. PMID: 22504213 https://doi.org/10.1213/ANE.0b013e318251daed

12. Gulur P., Tsui B., Pathak R., Koury K.M., Lee H. Retrospective analysis of the incidence of epiduralhaematoma in patients with epidural catheters and abnormal coagulation parameters. Br J Anaesth. 2015;114(5):808–811. PMID: 25614136 https://doi.org/10.1093/bja/aeu461

13. Ehrenfeld JM, Agarwal AK, Henneman JP, Sandberg WS. Estimating the Incidence of Suspect-ed Epidural Hematoma and the Hidden Imaging Cost of Epidural Catheterization: A Retrospective Review of 43,200 Cases. Reg Anesth Pain Med. 2013;38(5):409–414. PMID: 23924685 https://doi.org/10.1097/AAP.0b013e31829ecfa6

14. Pitkänen MT, Aromaa U, Cozanitis DA, Förster JG. Serious complications associated with spi-nal and epidural anaesthesia in Finland from 2000 to 2009. Acta Anaesthesiol Scand. 2013;57:553–564. PMID: 23305109 https://doi.org/10.1111/aas.12064

15. Van Veen JJ, Nokes TJ, Makris M. The risk of spinal haematoma following neuraxial anaesthesia or lumbar puncture in thrombocytopenic individuals. Br J Haematol. 2010;148(1):15–25. PMID: 19775301 https://doi.org/10.1111/j.1365-2141.2009.07899.x

16. Cuypers V, Van de Velde M, Devroe S. Intracranial subdural haematoma following neuraxial anaesthesia in the obstetric population: a literature review with analysis of 56 reported cases. Int J Obstet Anesth. 2016;25:58–65. PMID: 26597409 https://doi.org/10.1016/j.ijoa.2015.09.003

17. Goodier CG, Lu JT, Hebbar L, Segal BS, Goetzl L. Neuraxial Anesthesia in Parturients with Thrombocytopenia: A Multisite Retrospective Cohort Study. Anesth Analg. 2015;121(4):988–991. PMID: 26378701 https://doi.org/10.1213/ANE.0000000000000882

18. Ruppen W, Derry S, McQuay H, Moore RA. Incidence of Epidural Hematoma, Infection, and Neurologic Injury in Obstetric Patients with Epidural Analgesia/Anesthesia. Anesthesiology. 2006;105(2):394–399. PMID: 16871074 https://doi.org/10.1097/00000542-200608000-00023

19. D’Angelo R, Smiley RM, Riley ET, Segal S. Serious Complications Related to Obstetric An-esthesia The Serious Complication Repository Project of the Society for Obstetric Anesthesia and Perinatology. Anesthesiology. 2014;120(6):1505–1512. PMID: 24845921 https://doi.org/10.1097/ALN.0000000000000253

20. Bernstein J, Hua B, Kahana M, Shaparin N, Yu S, Davila-Velazquez J. Neuraxial Anesthesia in Parturients with Low Platelet Counts. Anesth Analg. 2016;123(1):165–167. PMID: 27159067 https://doi.org/10.1213/ANE.0000000000001312

21. Tanaka M, Balki M, McLeod A, Carvalho JCA. Anestesia Regional e Trombocitopenia Não Pré-Eclâmptica; Hora de Repensar o Nível Seguro de Plaquetas. Revista Brasileira de Anestesiologia. 2009;59(2):142–153. PMID: 19488526 https://doi.org/10.1590/S0034-70942009000200002

22. Ray N. P. Can We Continue to Deny Neuraxial Anesthesia to Otherwise-Healthy Parturients With Thrombocytopenia? Anesth Analg. 2017;124(2):704–705. PMID: 28098703 https://doi.org/10.1213/ANE.0000000000001785

23. Bergmann F, Rath W. The Differential Diagnosis of Thrombocytopenia in Pregnancy. Dtsch Arztebl Int. 2015;112(47):795–802. PMID: 26634939 https://doi.org/10.3238/arztebl.2015.0795

24. Wang X, Xu Y, Luo W, Feng H, Luo Y, Wang Y, et al. Thrombocytopenia in pregnancy with different diagnoses Differential clinical features, treatments, and outcomes. Medicine (Baltimore). 2017;96(29):e7561. PMID: 28723784 https://doi.org/10.1097/MD.0000000000007561

25. Camann W. Obstetric Neuraxial Anesthesia Contraindicated? Really? Time to Rethink Old Dogma. Anesth Analg. 2015;121(4):846–848. PMID: 26378695 https://doi.org/10.1213/ANE.0000000000000925

26. Lee LO, Bateman BT, Kheterpal S, Klumpner TT, Housey M, Aziz MF, et al. Risk of Epidural Hematoma after Neuraxial Techniques in Thrombocytopenic Parturients. A Report from the Multi-center Perioperative Outcomes Group. Anesthesiology. 2017;126(6):1053–1064. PMID: 28383323 https://doi.org/10.1097/ALN.0000000000001630

27. Orlikowski CE, Rocke DA, Murray WB, Gouws E, Moodley J, Kenoyer DG, et al. Thrombelas-tography changes in pre-eclampsia and eclampsia. Br J Anaesth. 1996;77(2):157–161. PMID: 8881617 https://doi.org/10.1093/bja/77.2.157

28. Huang J, McKenna N, Babins N. Utility of Thromboelastography During Neuraxial Blockade in the Parturient with Thrombocytopenia. AANA J. 2014;82(2):127–130. PMID: 24902455

29. Katz D, Beilin Y. Disorders of coagulation in pregnancy. Br J Anaesth. 2015;115(2):75–88. PMID: 26658204 https://doi.org/10.1093/bja/aev374

30. Reese JA, Peck JD, Deschamps DR, McIntosh JJ, Knudtson EJ, Terrell DR, et al. Platelet counts during pregnancy. N Engl J Med. 2018;379:32–43. https://doi.org/10.1056/NEJMoa1802897