The authors of this retrospective analysis assessed the anesthetic management, complications, and outcomes in parturients with thrombocytopenia to add to the existing data regarding the safety of neuraxial blocks in these patients. The study was performed at a maternity and women’s hospital in Israel. All women with a platelet count <100,000/µL admitted for delivery between 2011 and 2014 were included in the study. These patients were then further categorized into 1 of 3 groups based on their platelet count: 0 to 49,000, 50 to 69,000, and 70 to 99,000/µL. The primary outcome of the study was the rate of neuraxial block for each of the 3 study groups. Secondary outcomes analyzed included the frequency of general anesthesia for cesarean delivery, urgency of cesarean delivery, length of hospitalization, and the rate of SEH.
A total of 471 women of 45,462 (1%) had a platelet count <100,000/µL. The rate of neuraxial block for women with thrombocytopenia was inversely related to the platelet count range. Women with platelet counts of 70 to 99,000/µL were significantly more likely to undergo a neuraxial procedure (71.1%) compared with women with platelet counts of 50 to 69,000/µL (38.9%) and 0 to 49,000/µL (27.8%) with P-values <0.0001. The duration of hospital stay was significantly longer in women in the lowest platelet count group, which the authors thought was likely due to the patients’ underlying conditions that resulted in thrombocytopenia. The rate of cesarean delivery was similar regardless of platelet count range; however, general anesthesia was more frequently used among women in the lower platelet count ranges (11.9% for 70 to 99,000/µL group, 55.6% for 50 to 69,000/µL group, and 66.7% for 0 to 49,000/µL, P<0.0001). No SEHs or any other neurologic complications were reported among the 308 women who received neuraxial blocks. The authors added these cases to the other previously reported neuraxial blocks in thrombocytopenic parturients. This resulted in a total sample of 1832 blocks. They then calculated the upper limit of the 95% confidence interval for the risk of SEH in this patient population, which was 0.16%. Of note, thromboelastography was performed in 20 (4%) thrombocytopenic patients in the current study; none of these tests showed evidence of coagulopathy.
In conclusion, while neuraxial block was avoided in the majority of women with platelet counts below 70,000/µL, the study findings further support the belief among most obstetric anesthesiologists that the risk of SEH is extremely low in women with platelet counts <100,000/µL, especially those in the range of 70 to 100,000/µL.
Many anesthesiologists have a visceral reaction when asked to place a neuraxial anesthetic in the parturient with thrombocytopenia. Original recommendations from the 1980s were to avoid placement if the platelet count was <100,000/mm3.1 This recommendation is engrained in our culture and to this day I am aware of too many institutions that still follow this suggestion. This is despite evolving literature demonstrating the safety of placing neuraxial anesthesia and the absence of literature showing development of epidural hematomas in parturients with thrombocytopenia.2,3
In my opinion the platelet count is only 1 piece of the puzzle when evaluating the patient with thrombocytopenia. Platelets are only 1 component of the coagulation system and many patients won’t bleed with very low platelet counts and some will bleed with higher counts. The more important question is whether the patient has any bleeding history. If a patient has a chronically low platelet count (perhaps from idiopathic thrombocytopenia) and they have never bled and don’t bruise easily then that patient is a candidate for neuraxial anesthesia. The key is that decisions about whether to perform neuraxial anesthesia must be individualized to each patient.
The study by Levy et al4 is a welcome addition to the literature for 2 reasons. First, it is reassuring and important to report that some patients (28%) received neuraxial anesthesia at platelet counts <50,000/mm3 without complications. Second, they have added 308 additional patients to the literature who received a neuraxial anesthesia with a platelet count <100,000/mm3. It is studies such as this one that will hopefully change our culture and encourage others to consider epidural placement in the face of thrombocytopenia.
Comment by Yaakov Beilin, MD
1. Cousins MJBPCousins MJ, Bridenbaugh PO. Epidural neural blockade. Neural Blockade in Clinical Anesthesia and Management of Pain, 2nd ed. Philadelphia, PA: J.B. Lippincott Company; 1988:335–336.
2. Bernstein J, Hua B, Kahana M, et al. Neuraxial anesthesia in parturients with low platelet counts. Anesth Analg. 2016;123:165–167.
3. Lee LO, Bateman BT, Kheterpal S, et al. Risk of epidural hematoma after neuraxial techniques in thrombocytopenic parturients: a report from the Multicenter Perioperative Outcomes Group. Anesthesiology. 2017;126:1053–1063.
4. Levy N, Goren O, Cattan A, et al. Neuraxial block for delivery among women with low platelet counts: a retrospective analysis. Int J Obstet Anesth. 2018;35:4–9.