RA and Coagulation

Wider Scope
  • Thromboprophylaxis during pregnancy, labour and after delivery
General Points
  • Most guidelines provide advice about placement of regional blocks in patients on aspirin and heparin (both prophylactic and treatment doses)
  • Risk/benefit analysis of regional blocks in patients with low platelets was provided in most guidelines.
  • Management of patients suspected of having epidural haematoma was provided with emphasis on early neurosurgical opinion and MRI.
  • Variation in platelet numbers acceptable prior to inserting regional block - most units using 75 to 80 X 109 / l as their usual lower limit.
  • Most units specified minimum time frames after giving heparin before siting Regional block – most commonly, (range in brackets):-
  • After prophylactic unfractionated s.c. heparin 6 hours
  • After prophylactic LMW heparin 12 (10-12) hours and 4 (2-4) hours wait before next dose
  • After treatment dose LMW heparin, 24 (22-24) hours and 4 hours wait before next dose
We Liked
  • Guidance of time frame for checking platelets prior to regional block in preeclampsia.
  • Reminder of risk of thrombocytopenia following even short time use of heparin.
  • Doses given for ‘high dose’ / ‘low dose’ LMWH.
  • Listing of other medical or obstetric conditions that could give rise to suspect coagulation abnormalities.
  • Very clear, practical advice about platelet count (UHL - C)
  • 'Allocate a scribe' (UHL - MOH)
  • Attention to non-transfusion measures (UHL - MOH)
  • Early TXA (UHL - MOH)
We Didn't Like
  • Not making clear that decisions on whether to proceed with regional block are based on assessment of risk / benefit balance by senior anaesthetist rather than absolute number
  • Slightly at odds with AAGBI guidance that encourages movement away from absolute cut offs (UHL - C)
  • Many centres now have easy availability of Xa monitoring (UHL -C)
  • Does not state which LMWH is being referred to with the dosing guide (UHL - C)
  • Very early FFP (this is becoming controversial in MOH with regard to diluting fibrinogen levels) (UHL - MOH)
  • Mention of fibrineogen concentrate/cryoprecipitate comes rather late
Not Sure
  • Consensus is that spinal needles are safer because they are smaller.
  • Important to differentiate between low steady platelet numbers as in ITP and rapidly falling numbers when deciding management.
  • Possible use of Desmopressin in low platelet counts.
  • This is a good, didactic guide for juniors but if it were to be adopted as a guideline it might make it difficult for more senior clinicians who may have good reason not to follow it in certain clinical scenarios. (UHL - C)
  • The 8 hour recommendation for LMWH administration after catheter insertion or removal when it has been a traumatic insertion is unusual (UHL - C)
  • Could include references for completeness (UHL - C)
  • The use of O negative blood versus group specific blood. Most pregnant women have booking bloods taken - if this includes a G&S then group specific blood should be an option for most women without having to deplete supplies of O neg (UHL - MOH)
  • Ergometrine reocommended IV should probably mandate an anti-emetic, what about giving it IM? (UHL - MOH)
  • Misprostol for PPH s falling out of favour (UHL - MOH)
  • Also could mention an Art line and possibility of interventional radiology? (UHL - MOH)

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