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The Society for Obstetric Anesthesia and Perinatology Consensus Statement on the Anesthetic Management of Pregnant and Postpartum Women Receiving Thromboprophylaxis or Higher Dose Anticoagulants

Leffert, Lisa, MD*; Butwick, Alexander, MBBS, FRCA, MS; Carvalho, Brendan, MBBCh, FRCA, MDCH; Arendt, Katherine, MD; Bates, Shannon M., MDCM, MSc§; Friedman, Alex, MD; Horlocker, Terese, MD; Houle, Timothy, PhD*; Landau, Ruth, MD; Dubois, Heloise, BS; Fernando, Roshan, MBChB, FRCA; Houle, Tim, PhD; Kopp, Sandra, MD; Montgomery, Douglas, MD; Pellegrini, Joseph, PhD, CRNA, FAAN; Smiley, Richard, MD, PhD; Toledo, Paloma, MD, MPH the members of the SOAP VTE Taskforce

doi: 10.1213/ANE.0000000000002530
Obstetric Anesthesiology: Special Article
Continuing Medical Education

Venous thromboembolism is recognized as a leading cause of maternal death in the United States. Thromboprophylaxis has been highlighted as a key preventive measure to reduce venous thromboembolism–related maternal deaths. However, the expanded use of thromboprophylaxis in obstetrics will have a major impact on the use and timing of neuraxial analgesia and anesthesia for women undergoing vaginal or cesarean delivery and other obstetric surgeries. Experts from the Society of Obstetric Anesthesia and Perinatology, the American Society of Regional Anesthesia, and hematology have collaborated to develop this comprehensive, pregnancy-specific consensus statement on neuraxial procedures in obstetric patients receiving thromboprophylaxis or higher dose anticoagulants. To date, none of the existing anesthesia societies’ recommendations have weighed the potential risks of neuraxial procedures in the presence of thromboprophylaxis, with the competing risks of general anesthesia with a potentially difficult airway, or maternal or fetal harm from avoidance or delayed neuraxial anesthesia. Furthermore, existing guidelines have not integrated the pharmacokinetics and pharmacodynamics of anticoagulants in the obstetric population. The goal of this consensus statement is to provide a practical guide of how to appropriately identify, prepare, and manage pregnant women receiving thromboprophylaxis or higher dose anticoagulants during the ante-, intra-, and postpartum periods. The tactics to facilitate multidisciplinary communication, evidence-based pharmacokinetic and spinal epidural hematoma data, and Decision Aids should help inform risk–benefit discussions with patients and facilitate shared decision making.

From the *Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts

Department of Anesthesia, Stanford University School of Medicine, Stanford, California

Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota

§Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada

Departments of Obstetrics and Gynecology

Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York.

Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts

Department of Anaesthesia and Perioperative Medicine, University College London Hospital, London, United Kingdom

Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts

Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota

Kaiser Permanente Riverside Medical Center, Riverside, California

Department of Organizational Systems and Adult Health, Nurse Anesthesia Program, University of Maryland School of Nursing, Baltimore, Maryland

Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York; he reports stocks owned by spouse from Abbott Labs, Amgen, and Abbvie, outside of the submitted work

Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois

Published ahead of print November 1, 2017.

Accepted for publication August 24, 2017.

Funding: None.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

The Appendix provides the full list of the SOAP VTE Taskforce members, along with their respective affiliations.

Reprints will not be available from the authors.

Address correspondence to Lisa Leffert, MD, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114. Address e-mail to lleffert@partners.org.

© 2018 International Anesthesia Research Society
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