|Year : 2021 | Volume
| Issue : 2 | Page : 135-137
Spinal Anesthesia for Cesarean Section in a Coagulated Patient with Antiphospholipid Syndrome
Pontisomaya Parami, Win Muliadi, Tjahya Aryasa, Christopher Ryalino
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Bali, Indonesia
|Date of Submission||19-Oct-2020|
|Date of Decision||06-Dec-2020|
|Date of Acceptance||08-Dec-2020|
|Date of Web Publication||16-Apr-2021|
Dr. Christopher Ryalino
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Jl. PB Sudirman, Denpasar 80232, Bali
Source of Support: None, Conflict of Interest: None
Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by vascular thrombosis or pregnancy complications with the presence of antiphospholipid antibodies. It is a rare disease affecting 40–50/100,000 population yet responsible for 10%–15% of recurrent pregnancy loss. Diagnosis requires at least one clinical and one laboratory criteria to be met. Perioperative management in obstetric APS underwent cesarean section stressed on the management of anticoagulation and proper choice of anesthesia technique. We report the case of a 21-years-old woman, 39 weeks pregnant, diagnosed with APS since the 8th week of gestation. She had two previous miscarriages and an elevated level of anticardiolipin antibody (aCL IgG: 21 GPL U/ml) with normal aCL IgM and lupus anticoagulant. She was treated with a prophylactic dose of low-molecular-weight heparin (0.4 IU subcutaneous enoxaparin) and oral aspirin 80 mg daily. She presented to the obstetric department and scheduled for an urgent cesarean section. Enoxaparin was held, and the surgery was done with spinal anesthesia. Anticoagulation resumed 12 h after surgery. No complications on the mother and baby were found after 3 days of observation.
Keywords: Anticoagulation, antiphospholipid syndrome, pregnancy, spinal anesthesia
|How to cite this article:|
Parami P, Muliadi W, Aryasa T, Ryalino C. Spinal Anesthesia for Cesarean Section in a Coagulated Patient with Antiphospholipid Syndrome. Bali J Anaesthesiol 2021;5:135-7
|How to cite this URL:|
Parami P, Muliadi W, Aryasa T, Ryalino C. Spinal Anesthesia for Cesarean Section in a Coagulated Patient with Antiphospholipid Syndrome. Bali J Anaesthesiol [serial online] 2021 [cited 2021 Jul 25];5:135-7. Available from: https://www.bjoaonline.com/text.asp?2021/5/2/135/313891
| Introduction|| |
Antiphospholipid syndrome (APS) is an acquired disorder that was first described in 1983 as an anticardiolipin syndrome. It is a systemic autoimmune disease characterized by vascular thrombosis or pregnancy complications associated with persistent antiphospholipid antibodies. It is estimated to affect 40–50/100,000 population and accounts for 10%–15% of recurrent pregnancy loss., We report a case of APS in pregnancy due to its rarity.
| Case Report|| |
A 21-year-old woman, 39 weeks pregnant, presented to the obstetric department with a chief complaint of vaginal watery discharge since 12 h before admission. She also complained the baby's movement was reduced with no abdominal cramps or bloody show. She had a regular checkup with an obstetrician, and she also had a poor obstetric record with two previous miscarriages at 16 and 10 weeks of pregnancy. In this pregnancy, she was consulted to the hematology department and was diagnosed with APS (aCL IgG: 21 GPL U/ml, aCL IgM: 4 MPL U/ml, and lupus anticoagulant [LA]: 39.10 s), and she was treated with subcutaneous enoxaparin 0.4 IU every 24 h and aspirin 80 mg every 24 h since her 8th weeks of pregnancy.
On admission, the vital signs were stable. Obstetric examination showed a fetal heart rate of 124 times/min with a nonreactive fetal nonstress test (NST). Complete blood count showed hemoglobin of 12.56 g/dl, hematocrit – 38.14%, white blood cell – 9.11 × 103/mcL, and platelet – 261.10 × 103/mcL. The coagulation study showed a prothrombin time of 12.7 s (10.8–14.4), international normalized ratio – 0.90, and activated partial thromboplastin time – 31.7 s (24–36). Due to nonreactive NST and premature rupture of membrane, she was then scheduled for an urgent cesarean section. Intravenous cefazoline 2 g was administered as prophylaxis. Enoxaparin was stopped 12 h before surgery, and aspirin was withheld on the day of surgery.
The surgery was done with spinal anesthesia. Standard monitoring was applied in preparation room, blood pressure was 115/73 mmHg, heart rate – 85 times/min, respiratory rate – 16 times/min, and SpO2 – 99% on nasal cannulae 2 lpm. The spinal anesthesia was done with 12.5 mg bupivacaine heavy 0.5% on L2–3 with Quincke needle 27 G. Incision was started after anesthesia is confirmed to reach the dermatome level of T6. A male baby was born 5 min after incision, weighed 3300 g, 50 cm length, and Apgar score 7–8. Neonatal heart rate was 148 times/min, respiratory rate – 46 times/min, SpO2 – 90%, and no congenital malformation was found. Oxytocin was administered after delivery. The patient was hemodynamically stable during surgery. She received 850 ml of crystalloids, and blood loss was 450 ml. The surgery lasted for 40 min.
After surgery, the patient and her baby were transferred to the general ward. Enoxaparin 0.4 IU 24 hourly was resumed 12 h after surgery, and aspirin was discontinued. She was given postoperative analgesia with intravenous morphine for 24 h and changed to mefenamic acid and oral paracetamol. No significant complication was noted after 3 days of observation of the mother and neonate. A phone call follow-up 3 months after surgery revealed no significant complaint.
| Discussion|| |
APS is characterized by thrombotic and obstetric manifestations (e.g., miscarriages) associated with antiphospholipid antibodies. Currently, there are three well-established antiphospholipid antibodies: LA, anticardiolipin antibody (aCL), and anti-b2 glycoprotein I antibody (ab2GPI). Based on revised criteria by Miyakis et al. in 2006, APS is present if meeting at least one clinical and one laboratory criteria. According to the Indonesian Rheumatology Association, the laboratory criteria for APS require positive LA, moderate or high titer anticardiolipin antibody (without specification of quantity), and/or ab2GPI.
The patient presented with two unexplained death of the fetus beyond the 10th week of gestation. There was no evidence of fetal abnormality recorded. There was also no sign of arterial, venous, or small vessel thrombosis. She was checked for antiphospholipid antibodies and showed moderate elevation on aCL IgG. aCL IgM and LA were not elevated, and ab2GPI was not checked. Thus, she was diagnosed with APS, and the treatment was started without a second laboratory test 12 weeks apart, considering that delaying treatment by 12 weeks might poorly affect fetal development.
APS is managed in conjunction with a hematologist and, if associated with autoimmune disease (systemic lupus erythematosus), may also be managed by a rheumatologist. An obstetrician must be involved in obstetric APS. The current treatment recommendation for obstetric APS is low-dose aspirin and a prophylactic dose of low-molecular-weight heparin. However, up to 20% of pregnancies are unsuccessful despite treatment. Risk factors of unsuccessful pregnancy include triple antiphospholipid antibody positivity, associated autoimmune disease, and thrombotic manifestations. In this case, she was consulted to the hematology department and managed with aspirin 80 mg oral and enoxaparin 0.4 IU subcutaneously once daily since the 8th week of gestation.
Anesthesia of patients with APS undergoing surgery could be done with general or regional anesthesia. Most patients diagnosed with APS would receive anticoagulation medications, therefore it raised concerns of complications that might occur after neuraxial anesthesia such as spinal hematoma. Nevertheless, in obstetric patients, neuraxial anesthesia provides several fetal and maternal advantages compared to general anesthesia. As long as the coagulation profile is within normal range and anticoagulation was held for an appropriate duration, neuraxial anesthesia could be safely performed on a patient with APS., The American Society of Regional Anesthesia and Pain Medicine also provides the same recommendation.
According to Douketis et al., the patient could be classified as high risk of perioperative thromboembolism. Nevertheless, considering bleeding risk in cesarean section, the aspirin therapy was held on the day of surgery. She was using enoxaparin 0.4 IU (prophylactic dose), and the last dose was >12 h before surgery. Spinal anesthesia is used, with Quincke needle 27G on lumbar L2–3. There were no complications (e.g., spinal hematoma) noted during and immediately after surgery.
As the postpartum period increases the risk of thrombosis, the anticoagulation was resumed 12 h after surgery. Aspirin was stopped after delivery as there was no clear benefit of low dose aspirin in nonobstetric APS. Optimal analgesia is imperative to facilitate early mobilization to reduce the risk of postoperative thrombotic events. This patient received intravenous morphine with oral paracetamol for the 1st day and changed to oral mefenamic acid and paracetamol for days 2 and 3. The postoperative numerical pain scale was ≤3, and she was able to sit and walk since the 1st day after surgery.After three days of observation, we found no headache, backpain, or other neurological symptoms, and no sign of thrombosis or abnormal bleeding. No significant complaint was found on follow-up call 3 months after surgery.
| Conclusion|| |
A successful outcome in a patient with APS requires a multidisciplinary approach to prevent both thrombotic and hemorrhagic complications. For obstetric APS cases, anticoagulation should be managed carefully, as a thrombotic event could have a devastating effect on the fetus. Anesthesiologists should be well aware of perioperative complications associated with APS and the associated use of anticoagulation. Proper timing to hold and resume anticoagulation, especially during neuraxial anesthesia, is essential to prevent complications. This case showed an obstetric APS case on anticoagulation undergoing cesarean section successfully managed with spinal anesthesia.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest
| References|| |
Hughes GR. Thrombosis, abortion, cerebral disease, and the lupus anticoagulant. Br Med J (Clin Res Ed) 1983;287:1088-9.
Miyakis S, Lockshin MD, Atsumi T, Branch DW, Brey RL, Cervera R, et al
. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome. J Thromb Haemost 2006;4:295-306.
Gómez-Puerta JA, Cervera R. Diagnosis and classification of the antiphospholipid syndrome. J Autoimmun 2014;48-49:20-5.
Rai RS, Regan L, Clifford K, Pickering W, Dave M, Mackie I, et al
. Antiphospholipid antibodies and β2-glycoprotein-I in 500 women with recurrent miscarriage: Results of a comprehensive screening approach. Hum Reprod 1995;10:2001-5.
Giannakopoulos B, Krillis SA. The pathogenesis of antiphospholipid syndrome. N Eng J Med 2013;368:1033-44.
Fanouriakis A, Kostopoulou M, Alunno A, Aringer M, Bajema I, Boletis JN, et al
. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Annals of the Rheumatic Diseases 2019;78:736-745.
Mezhov V, Segan JD, Tran H, Cicuttini FM. Antiphospholipid syndrome: A clinical review. Med J Aust 2019;211:184-8.
de Jesus GR, dos Santos FC, Oliveira CS, Mendes-Silva W, de Jesus NR, Levy RA, et al.
Management of obstetric antiphospholipid syndrome. Curr Rheumatol Rep 2012;14:79-86.
Ruffatti A, Tonello M, Visentin MS, Bontadi A, Hoxha A, De Carolis S, et al
. Risk factors of pregnancy failure in patients with antiphospholipid syndrome treated with conventional therapies: A multicentre, case-control study. Rheumatology (Oxford) 2011;50:1684-9.
Kim JW, Kim TW, Ryu KH, Park SG, Jeonng CY, Park DH. Anaesthetic considerations for patients with antiphospholipid syndrome undergoing non-cardiac surgery. J Int Med Res 2020;48:1-25.
Bernstein J, Hua B, Kahana M, Shaparin N, Yu S, Davilla-Velazquez J. Neuraxial anaesthesia in parturients with low platelet counts. Anesth Analg 2016;123:165-7.
Gorgaten W, Vandermeulen R, Van Aken H, Kozek S, Liau JV, Samama CM. Regional anaesthesia and antithrombotic agents: Recommendations of the European Society of Anesthesiology. Eur J Anaesthesiol. 2010;27:999-1015.
Horlocker TT, Vandermeuelen E, Kopp SL, Gogarten W, Leffert LR, Benzon HT. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American society of regional anesthesia and pain medicine Evidence-based guidelines (fourth edition). Reg Anesth Pain Med 2018;43:263-309.
Douketis JD, Spyropoulos AC, Spenceer PA. Perioperative management of antithrombotic therapy: Antithrombotic therapy and prevention of thrombosis, 9th
ed.: American college of chest physicians evidence-based clinical practice guidelines. Chest 2012;141 (2 suppl):e326S-50S.
Keeling D, Mackie I, Moore GW, Greer IA, Graves M. Guidelines on the investigation and management of antiphospholipid syndrome. Br J Haematol. 2012;157:47-58.