Thread by @OBsleepmerchant

@LimGrapes continues her tour de force at #OAA23ASM with Decision Making and Neuraxial Anesthesia. New evidence around thrombocytopenia and how those guidelines affect decision making in #OBAnes

To start: a Case. Possible evolving HELLP. Trends are important. Discuss anesthesia options.
#OBAnes #OAA23ASM

Defining the problem: preeclampsia itself results in qualitative platelet dysfunction (even before HELLP). Preeclampsia has circulating microthrombi. Platelets are pre-activated, proaggregatory and prothrombotic BUT don’t respond to exposed collagen —> perioperative bleeding… twitter.com/i/web/status/1…

And what of HELLP? ?most severe spectrum of preeclampsia? Associated with worst outcomes, with significant consequences. DIC, abruption and acute renal failure = top 3, but others no less disastrous.
#OBAnes #OAA23ASM

@LimGrapes highlights the elephant in the room when we discuss neuraxial and thrombocytopenia: spinal epidural hematoma (SEH). Overall prevalence in general population 1: 100,000 (my eyes went wide too) - most often venous, asymptomatic; multiple causes (including spontaneous,… twitter.com/i/web/status/1…

Is post-neuraxial epidural hematoma always direct needle trauma? NO 😱 multiple possible mechanisms. In preeclampsia these non-trauma mechanisms are exacerbated by platelet dysfunction and impaired coagulation —> higher risk of SEH, WITH or WITHOUT neuraxial. #OBAnes #OAA23ASM

Preeclampsia is a risk factor for neuraxial hematoma, associated with a FOUR fold increase in stroke during pregnancy (an important risk factor for both ischemic & hemorrhagic). Clinical presentation - pain, sensory and motor deficits are 🚩🚩🚩. Patients eligible for… twitter.com/i/web/status/1…

New evidence. Risk of epidural hematoma after Neuraxial in thrombocytopenic parturients (Lee LO et al @_Anesthesiology 2017). Very few SEH require surgical decompression, despite increasing risk as platelet number decreases (systematic review data <50k = 20%). #OBAnes #OAA23ASM

The magic area where data for low risk exists? >70k platelets within 6hours of neuraxial placement. Once the MPOG data was added to the systematic review data the risk decreases further (<50k now 11%). This data results in the @SOAPHQ interdisciplinary consensus statement on… twitter.com/i/web/status/1…

The @SOAPHQ consensus statement algorithm, and where preeclampsia & HELLP sits. Assessment of bleeding is more nuanced than simple yes/no questions around heavy period/ easy bruising (binary questions will over diagnose) - see Lisa Leffert, @MelissaEBauer1 @dr_melissabyrne… twitter.com/i/web/status/1…

Does TEG/ FIBTEM/ROTEM help? We don’t know - perfect research opportunity (hint, hint).

Summary of @SOAPHQ consensus statement: >70k platelets (within last 6 hrs) risk LOW in absence of other risk factors. Clinical context important. #OBAnes #OAA23ASM

Obligatory subsequent editorial comment: are we being too conservative? Are there better tests? (I know @bhwords has suggested 50k #OAA3dc2019 - probably lower by now)

50-69k and likely <50k will be acceptable in certain #OBAnes contexts, and we have data to enjoy more educated/… twitter.com/i/web/status/1…

And what happened to that case? Shared decision making and excellent documentation (even @BogodDavid would be pleased) Excellent outcome. #OBAnes #OAA23ASM

Conclusions. Preeclampsia is a risk factor for epidural hematoma. Platelet count AND function matter. There is a consensus statement to guide us. Any questions, ask a jet lagged @LimGrapes. #OBAnes #OAA23ASM

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