Platelet Count for Labor Epidural

[DreamMachine]

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I did a search.

I have a lady that wants a labor epidural. Her platelet count is 60,000. She has HELLP syndrome.

What your cutoff for platelet count? Do you have a cutoff to begin with?

What additional information would you like to know and why?

What's the lowest platelet count you have put a labor epidural in?

 

[smgilles]

I did a search.

I have a lady that wants a labor epidural. Her platelet count is 60,000. She has HELLP syndrome.

What your cutoff for platelet count? Do you have a cutoff to begin with?

What additional information would you like to know and why?

What's the lowest platelet count you have put a labor epidural in?

I want to know the trend of her platelets. Were they 100,000 yesterday? If they were 63,000 the day before I am not as worried. Also what's her airway look like? 50,000 would be my cut off for neuraxial anesthesia.

 

[jwk]

Blade and others, including me, had this discussion recently, so you can do a search for that thread.

Our cutoff is 100k. Lots of people thought that was too high, and that those with lower counts are still acceptable candidates for neuraxial techniques, especially a spinal with a 30ga needle. To each his own. I can tell you we would never stick a needle in someone's back with a 50-60k platelet count under any circumstances.

However, with documented HELLP syndrome, and platelets already down to 60k, I think proceeding with a spinal or epidural would be an unacceptable risk even for those who might otherwise do it at that level.

 

[Bertelman]

I wouldn't touch it. We usually consider platelets around 80k to be the cutoff. I might consider it around 70 or so, particularly if she doesn't have HELLP, and documented hx of platelets that low for an extended period.

 

[coprolalia]

The ASRA guidelines indicate that, even in the obstetric population, the likelihood of concomitant aspirin therapy (qualitative platelet dysfunction) does not confer greater risk for spinal or epidural hematoma. HELLP syndrome represents a sequestration, and therefore quantitative decrease, in platelets. This is in the background of a pro-coagulative state of pregnancy. Remember that the problem with the hematoma is when a catheter (or needle) is removed, not inserted.

At 60K, I would place a spinal, but be extra cautious (probably not) about an epidural. Benefit likely outweighs risk here, especially in c-section. Catch me at 25K and we would definitely have a different discussion.

-copro

 

[coprolalia]

Anesthesia in pregnant women with HELLP syndrome.
Vigil-De Gracia P, Silva S, Montufar C, Carrol I, De Los Rios S.

Gynecology and Obstetric Unit, Complejo Hospitalario Metropolitano de la Caja de Seguro Social, Panama, Panama. [email protected]

OBJECTIVE: Our purpose was to determine the types of anesthesia and neurologic or hematologic complications found in pregnancy with HELLP syndrome providing analgesia for cesarean section. METHODS: This is a retrospective study. For the period of 1 July 1996, through 30 June 2000, we reviewed the charts of all patients with HELLP syndrome who had cesarean section. RESULTS: During the period of study 119 patients had HELLP syndrome. Eighty-five patients had cesarean delivery and 34 had vaginal delivery. Seventy-one patients had diagnosed HELLP syndrome previous to the anesthesia and 14 postcesarean delivery; the range platelet count was 19000-143000/microl. Of these 71, 58 had an epidural anesthesia, 9 had general anesthesia and 4 had spinal anesthesia. There were no neurologic complications or bleeding in the epidural space. CONCLUSION: We found no documentation of any neurologic or hematologic complications of women with HELLP syndrome and neuraxial anesthesia.

http://www.ncbi.nlm.nih.gov/pubmed/11430937

-copro

 

[Narcotized]

I said no. Life becomes very different as an attending. Especially, as the new guy. I tend to take the most conservative approach to things. I don't need complications at this stage in the game.

Comes down to this, if you do something in a gray area where some would and some wouldn't, then a bad outcome will be seen as the result of you using poor judgement and you will get the blame.

 

[Noyac]

My impression is that it is probably ok to place the epidural. But the key word is "probably". I wouldn't touch this case. The only time I take chances is when the chance I am taking is not going to cause severe harm and is probably going to have bring great benefit. This is not one of those cases.

 

[pgg]

I did a search.

I have a lady that wants a labor epidural. Her platelet count is 60,000. She has HELLP syndrome.

What your cutoff for platelet count? Do you have a cutoff to begin with?

What additional information would you like to know and why?

What's the lowest platelet count you have put a labor epidural in?

I'm assuming you saw this thread.

I would not put an epidural in a HELLP'er at 60K. She may have further to fall, and as coprolalia pointed out removal is the riskier time.

I'd be comfortable doing a spinal for a section or perhaps as a single-shot bit of labor analgesia toward the end of labor, provided that 60K lab value was recent.

 

[cchoukal]

http://www.ncbi.nlm.nih.gov/pubmed/11430937

-copro

I appreciate that there are limited data in this population and that this retrospective review is likely the best study that exists, but I don't think a case series of 58 makes me feel any more comfortable about a complication that happens 1 in 100,000 in normal patients.

 

[coprolalia]

I appreciate that there are limited data in this population and that this retrospective review is likely the best study that exists, but I don't think a case series of 58 makes me feel any more comfortable about a complication that happens 1 in 100,000 in normal patients.

Yes, it is an incredibly rare complication.

-copro

 

[Idiopathic]

seeing an epidural hematoma will change your opinion of this, i think, but its so rare. ive seen one, and i think that id be willing to accept the risk of putting the patient to sleep versus performing epidural. if i could do the case with spinal then i may go that route, but i probably would not put an epidural in this lady, or at least i would be very careful taking it out (i.e. follow platelets and coags for a day).

i do also understand that the risk of GETA in this patient population is orders of magnitude higher than the risk of neuraxial complications.

 

[smgilles]

seeing an epidural hematoma will change your opinion of this, i think, but its so rare. ive seen one, and i think that id be willing to accept the risk of putting the patient to sleep versus performing epidural. if i could do the case with spinal then i may go that route, but i probably would not put an epidural in this lady, or at least i would be very careful taking it out (i.e. follow platelets and coags for a day).

i do also understand that the risk of GETA in this patient population is orders of magnitude higher than the risk of neuraxial complications.

Exactly and that is why I asked what does her airway look like? If it is a slam dunk airway then I lean towards GETA...if questionable then I am going to be more inclined to do neuraxial if her platelets have been stable at that 60,000 mark.

 

[Bertelman]

seeing an epidural hematoma will change your opinion of this, i think, but its so rare. ive seen one, and i think that id be willing to accept the risk of putting the patient to sleep versus performing epidural. if i could do the case with spinal then i may go that route, but i probably would not put an epidural in this lady, or at least i would be very careful taking it out (i.e. follow platelets and coags for a day).

i do also understand that the risk of GETA in this patient population is orders of magnitude higher than the risk of neuraxial complications.

From what I can tell of the OP, it's not about a C/S. This is analgesia for labor.

What it comes down to for me is whether I am willing to provide an analgesia technique which carries some unknown yet definite risk of tragic complication, and is basically indefensible in court, or if I would deny this and let her endure the labor without.

 

[Noyac]

seeing an epidural hematoma will change your opinion of this, i think, but its so rare. ive seen one, and i think that id be willing to accept the risk of putting the patient to sleep versus performing epidural. if i could do the case with spinal then i may go that route, but i probably would not put an epidural in this lady, or at least i would be very careful taking it out (i.e. follow platelets and coags for a day).

i do also understand that the risk of GETA in this patient population is orders of magnitude higher than the risk of neuraxial complications.

Is this true?

I am not aware of any studies comparing HELLP with plts 60K vs GETA in c/s. I haven't read everything but I just don't think you can make this statement. I wouldn't hesitate to put this pt to sleep unless something else was wrong like a bad airway. THen I'd do a spinal without any worries.

 

[pgg]

Is this true?

I think he was just referring to the elevated risk of GA in the pregnant population vs GA in the nonpregnant population. (Which I think most of us here agree is somewhat overblown.)

 

[cchoukal]

Besides, we aren't even talking about neuraxial vs. GA for a c/s. The OP is talking about epidural for elective labor analgesia (yes, we all know she'll probably go to section eventually). I think the GA vs. Spinal for her inevitable c/s is a different question, but without knowing more about her airway exam, I'm reluctant to weigh in on that question.

 

[urge]

I would stay away. 80k is the bottom of my comfort zone. Why risk lifetime paralysis for a few hrs of pain. Women go into labor all over the world without epidurals and do just fine. I would offer a pca instead.

 

[SleepIsGood]

it seems many of you would do a 'spinal'.

would any of you for labor analgesia (not a spinal) in THIS CASE take the time out to do a single shot spinal of an opiod (say 25 mcg of fent),etc?

 

[pgg]

As urge brings up, there are non-neuraxial options besides giving her a stick to bite. PCA is an option.

The OB could even get involved and do pudendal or paracervical blocks, though I expect to see that happen the day after I see one of them start a stat section under local.

Anyone still do paracervical blocks? I thought they'd fallen out of favor because of fetal exposure to high LA concentrations.

would any of you for labor analgesia (not a spinal) in THIS CASE take the time out to do a single shot spinal of an opiod (say 25 mcg of fent),etc?

I would; I mentioned that in my previous post, with the caveat that the lab result needs to be recent.

 

[Intubate]

The ASRA guidelines indicate that, even in the obstetric population, the likelihood of concomitant aspirin therapy (qualitative platelet dysfunction) does not confer greater risk for spinal or epidural hematoma. HELLP syndrome represents a sequestration, and therefore quantitative decrease, in platelets. This is in the background of a pro-coagulative state of pregnancy. Remember that the problem with the hematoma is when a catheter (or needle) is removed, not inserted.

At 60K, I would place a spinal, but be extra cautious (probably not) about an epidural. Benefit likely outweighs risk here, especially in c-section. Catch me at 25K and we would definitely have a different discussion.

-copro

Preeclampsia also causes qualitative decrease in platelet function. In idiopathic thrombocytopenia, function is normal or supranormal, but in HELLP syndrome you have a small number of poorly functioning platelets.

 

[Noyac]

Yes. So is your threshold higher with HELLP syndrome? How do you assess platelet function? Looking at the old thread you guys mentioned, TEG seems like the only answer. They don't do TEG where I work.

What are the downsides of not doing the epidural? From my understanding, there is greater likelihood of uncontrolled HTN and C-section. How significant is this? Any data on the increased rates of C-section in patients with pre-e, without epidural?

Also, how bad would the airway have to be to lower your threshold? This lady was fat and a MAL 3. Her airway didn't change my decision.

Her mouth would have to be wired shut.

 

[coprolalia]

Preeclampsia also causes qualitative decrease in platelet function. In idiopathic thrombocytopenia, function is normal or supranormal, but in HELLP syndrome you have a small number of poorly functioning platelets.

Let's make this more simple...

Are HELLP syndrome near parturients necessarily coagulopathic? (Think hard about that before you answer.)

-copro

 

[Intubate]

of course they're not "necessarily" coagulopathic. I was just making a clarification in your previous post.

 

[pgg]

Are HELLP syndrome near parturients necessarily coagulopathic? (Think hard about that before you answer.)

No. Where are you going with this?