May 5, 2021

Findings from a recently published study in the Journal of Anesthesia suggest that pregnant patients with hemophilia whose factor VIII or IX levels drop below 50% at the time of receiving neuraxial anesthesia are more likely to experience postpartum complications. Neuraxial anesthesia refers to the administration of local anesthetics and analgesia to targeted locations in the spinal area. Epidurals are a commonly utilized form of neuraxial anesthesia, often used as a method of pain relief during labor.   

Investigators were led by Brandon Togioka, MD, Associate Professor, Department of Anesthesiology and Perioperative Medicine at the Oregon Health & Science University in Portland. Togioka and his colleagues conducted two sets of literature reviews in October 2019. The first review, which included 13 articles, encompassed individual case reports and case series that described neuraxial techniques in patients with hemophilia—regardless of sex, age, or pregnant status. The second review, which included 19 articles, looked for case reports and series that outlined bleeding outcomes among pregnant patients.

Findings from the first review showed that 3 of 134 patients had neuraxial hematoma with paraplegia (paralysis of the legs and lower body). All three of these patients presented with a factor level of 1%. The second review showed that out of 2,712 deliveries, postpartum hemorrhage occurred in 193 patients (7.1%), which necessitated blood transfusion in 60% of these patients. Overall, postpartum bleeding complications were nearly “twice as likely” where factor levels were below 50%.

“In summary, we found low level evidence (Level 4) that factor VIII and IX levels should be greater than 50% for delivery and neuraxial techniques. In our review of 134 neuraxial placements and 2,712 deliveries, neuraxial hematomas were found with a factor level of 1% and hemorrhagic complications were higher when factor activity was <50%,” explained Togioka and his fellow authors. “Therefore, factor levels should be assessed and increased above 50% prior to neuraxial technique and delivery.The review , “Delivery and Neuraxial technique Outcomes in Patients with Hemophilia and in Hemophilia Carriers: A Systematic Review,” was published March 2021 in the Journal of Anesthesia.

Please note that earlier this year, NHF’s Medical and Scientific Advisory Council (MASAC) issued MASAC Document #265 which provides recommendations for the diagnosis and management of women with bleeding disorders during pregnancy, labor, and delivery. It also addresses the critical postpartum period with specific treatment recommendations designed to both mitigate the risk of bleeding-related complications in women and to enable the early diagnosis of affected infants. The document also does include recommendations on the appropriate use of neuraxial anesthesia.

View and download MASAC Guidelines for Pregnancy and Perinatal Management of Women with Inherited Bleeding Disorders and Carriers of Hemophilia A or B.

Source: Hematology Advisor, April 6, 2021

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