Neuraxial Procedures in Obstetric Patients With Thrombocytopenia

Publication Date: February 28, 2021
Last Updated: March 14, 2022

Recommendations

The Obstetric Patient With a Known Etiology of Thrombocytopenia by Prior Workup or Confirmed Diagnosis of Hypertensive Disorders of Pregnancya

1. Assess for history of bleeding associated with thrombocytopenia and confirm no visible signs of DIC such as bleeding from intravenous (IV) sites, catheters, wounds, or new mucocutaneous bleeding. (, )
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a. For confirmed diagnosis of gestational thrombocytopenia or ITP, or confirmed diagnosis of hypertensive disorders of pregnancy (eg, preeclampsia):
  • i. If concern for a history of bleeding associated with thrombocytopenia or DIC (as described above), then it may be reasonable to avoid neuraxial procedures or seek expert hematologic evaluation before proceeding with the neuraxial procedure.
(C-LD, IIb)
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  • ii. If the platelet count is ≥70,000 × 106 /L, then there is likely to be a low risk of spinal epidural hematoma and it is reasonable to proceed with a neuraxial procedure if clinically indicated.
(C-LD, IIa)
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  • iii. If the platelet count is between 50,000 and 70,000 × 106 /L, then there may be scenarios when competing risks/benefits justify proceeding with a neuraxial procedure.
(C-LDIIb)
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  • iv. If the platelet count is <50,000 × 106 /L, then there may likely be an increased risk of spinal epidural hematoma compared to a platelet count ≥70,000 × 106 /L and it may be reasonable to avoid neuraxial procedures.
(C-LD, IIb)
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b. If clinical scenario is consistent with hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome, then it may be reasonable to verify platelet count within 6 hours of the planned neuraxial procedure. (C-LDIIb)
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The Obstetric Patient Without a Known Etiology of Thrombocytopeniaa

1. Assess patient for bleeding history and possible underlying disorder of hemostasis (Table 2) and confirm no visible signs of DIC such as bleeding from IV sites, catheters, wounds, or new mucocutaneous bleeding. ()
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  • a. If concern for an underlying disorder of hemostasis or DIC (as described above), then it may be reasonable to avoid neuraxial procedures or seek expert hematologic consultation before proceeding with the neuraxial procedure.
(C-LD, IIb)
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  • b. If platelet count is <70,000 × 106 /L, then additional hematologic workup may be beneficial before proceeding with the neuraxial procedure.
(C-EOIIb)
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  • c. If there is no concern for an underlying disorder of hemostasis or DIC and the platelet count is ≥70,000 × 106 /L, then there is likely to be a low risk for spinal epidural hematoma and it is reasonable to proceed with neuraxial procedure if clinically indicated.a
(C-LDIIa)
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Other Recommendations

1. Aspirin, neuraxial procedures, and thrombocytopenia.
a. The taskforce members concluded that there was insufficient evidence to make a recommendation about performing neuraxial procedures in obstetric patients with thrombocytopenia taking aspirin.
2. Other laboratory testing and thrombocytopenia before neuraxial procedure.
a. The taskforce members concluded that there was insufficient evidence to make a recommendation about the use of additional laboratory tests (eg, PT, aPTT, TEG, ROTEM, and PFA) to aid in decision making regarding the safety of neuraxial anesthesia in obstetric patients with thrombocytopenia.
(, )
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a Assumes patient has no additional risk factors. Clinical context and competing risks might include, but are not limited to, the presence of high-risk comorbidities or difficult airway, the need for urgent or emergent general anesthesia, or the choice of neuraxial technique (ie, spinal versus epidural anesthetic).

Recommendation Grading

Overview

Title

Neuraxial Procedures in Obstetric Patients With Thrombocytopenia

Authoring Organization

Society for Obstetric Anesthesia and Perinatology

Endorsing Organizations

American College of Obstetricians and Gynecologists

American Society of Regional Anesthesia and Pain Medicine

Publication Month/Year

February 28, 2021

Last Updated Month/Year

April 1, 2024

Supplemental Implementation Tools

Document Type

Consensus

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Adult

Health Care Settings

Ambulatory, Emergency care, Hospital

Intended Users

Physician, nurse midwife, nurse, nurse practitioner, physician assistant

Scope

Assessment and screening, Prevention, Management

Diseases/Conditions (MeSH)

D013921 - Thrombocytopenia, D009774 - Obstetrics

Keywords

thrombocytopenia, Obstetric Anesthesia, Obstetric, Neuraxial Procedures, Perinatology

Methodology

Number of Source Documents
64
Literature Search Start Date
December 31, 2017
Literature Search End Date
November 30, 2019