Can We Continue to Deny Neuraxial Anesthesia to Otherwise-Healthy Parturients With Thrombocytopenia? (2017)

To the Editor Thank you for the publication entitled “Neuraxial Anesthesia in Parturients With Low Platelet Counts” by Bernstein et al.1 When reading this article, one cannot help to think that anesthesiologists continue to search for rare complications in one cohort of patients while ignoring the literature from another cohort of patients with similar clinical concerns. Children’s hospitals routinely perform lumbar punctures for intrathecal chemotherapy on oncology patients who have platelet counts as low as 20,000/mm3. Since 2005, prophylactic intrathecal chemotherapy has been administered for the prevention of central nervous system metastasis in patients with lymphoma/leukemia. In a series of 5223 lumbar punctures from 958 children, Howard et al2 reported no complications of spinal hematoma and a risk probability for spinal complications in patients with low platelet counts as follows:Skeptics may argue that the pathophysiology of thrombocytopenia in oncology is distinctly different to thrombocytopenia in parturients. Hematologists suggest that platelet function is better during pregnancy than in nonpregnant states. Parturients with von Willebrand disease experience an improvement of platelet function and a reduction of bleeding episodes during pregnancy because the circulating levels of factor VIII and von Willibrand factor are increased. Moreover, when quantifying platelet function during pregnancy using the PFA-100 analyzer (Dade Behring, Liederbach, Germany) Vincelot et al3 published that a platelet count of 60,000/mm3 in a parturient with pregnancy-induced thrombocytopenia functioned similarly to platelet counts that were greater than 150,000/mm3. To quote Goodier et al,4 “the unknown risk of hematoma continues to justify the decision to avoid neuraxial anesthesia in thrombocytopenic parturients.” As of July 2016, the Anesthesia (formerly ASA) Closed Claims Project database for events from 1990 to 2013 had no malpractice claims for spinal/epidural hematomas in parturients with thrombocytopenia.a Furthermore, of the 7 cases of epidural hematoma in obstetrics that have been reported since 1966, none of the patients had documented thrombocytopenia.4 The American Association of Blood Banks recently changed their guidelines so that a prophylactic platelet transfusion for elective lumbar punctures is no longer recommended when the platelet count is greater than 50,000/mm3. When confronted with the semiurgent situation of a parturient requiring a C-section with a platelet count below 100/mm3, anesthesiologists may require a platelet transfusion before proceeding with a neuraxial blockage or elect for general anesthesia. We know that platelet transfusions can cause ABO-incompatible transfusion reactions, acute lung injury, HLA allosensitization, and bacterial sepsis. In addition, exposing a developing newborn brain to general anesthesia has been a controversial issue in anesthesiology. The risk-adverse anesthesiologist may believe that by avoiding neuraxial anesthesia for a C-section to otherwise-healthy parturient with thrombocytopenia, they will be reducing potential risks to the patient. However, by subjecting the mother and fetus to a platelet transfusion and/or general anesthesia, the anesthesiologist will be adding addition risks to the patient that extend beyond the perioperative period. Neil P. Ray, MDDepartment of Anesthesiology and Pain MedicineUC Davis Medical CenterSacramento, California[email protected]