|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 || |
|Other || |
- 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)