Regional Anesthetics

and Anticoagulation
Objectives
Coagulation Cascade
Thromboembolic Disorders During
Pregnancy
Guidelines for regional anesthetics
and anticogulation
Coagulation Cascade
Conditions Warranting
Anticoagulation During Pregnancy
Mechanical prosthetic valve
Inherited deficiency of naturally occuring
anticoagulant:
Factor V Leiden
Protein C deficiency
Protein S deficiency
Antithrombin III deficiency
Prior episode of venous thromboembolism
Acute deep venous thrombosis or pulmonary
embolism during pregnancy
Antiphospholipid antibody syndrome
Mechanical Prosthetic Valves
Pregnant women with a prosthetic valve
are at high risk for thromboembolic
phenomena, valve failure and bacterial
endocarditis.

Complications from anticoagulation include
fetal teratogenicity, and maternal and
fetal hemorrhage

All pregnant women with a prosthetic
valve require anticoagulation
Mechanical Prosthetic Valves
Warfarin crosses the placenta and
has been associated with fetal
malformations and hemorrhage.

The teratogenic effects of warfarin
are limited to the first trimester. It
may be used in the second and third
trimester, but must be discontinued
prior to delivery.
Mechanical Prosthetic Valves
Heparin does not cross the placenta,
but can still cause maternal
hemorrhage.

Low molecular weight heparin has
also been used safely in pregnancy
as it does not cross the placenta.

Factor V Leiden
Factor V Leiden is a mutated form of
Factor V that is resistant to the
effects of activated protein C

Patients with FVL are at increased
risk for deep vein thrombosis.

Women with FVL are treated with
heparin during pregnancy.
Protein C Deficiency
Protein C is produced in the liver, requires
Vitamin K for synthesis
It acts by inhibiting activated factors V and VIII
Incidence 1:15,000
Levels of Protein C normally increase by 35% in
pregnancy
In patients with Protein C deficiency, thrombosis
occurs in 25% of pregnancies, unless
anticoagulation is administered.
Heparin is administered during the 1
st
and 3
rd

trimesters and heparin or warfarin during 2
nd

trimester and post-partum.
Protein S Deficiency
Protein S is produced by the liver
and requires Vitamin K for synthesis
Protein S is a cofactor for Protein C
The levels of Protein S normally
decrease during pregnancy
Heparin is administered in the 1
st

and 3
rd
trimester and warfarin or
heparin during the 2
nd
trimester and
postpartum
Antithrombin III Deficiency
Synthesized by liver and endothelial cells
It inactivates thrombin and factors IXa,
Xa, XIa and XIIa.
Incidence 1:5000
Risk of thrombosis iin pregnancy is 55%
68% in untreated patients.
Anticoagulation or antithrombin III
replacement is required in pregnancy
Heparin during 1
st
and 3
rd
trimester and
heparin or warfarin during he 2
nd
trimester
and postpartum
Venous Thromboembolism
Includes Deep Vein Thrombosis (DVT) and
Pulmonary Embolism (PE)
Incidence of DVT - 0.02% to 0.36% of all
pregnancies
Incidence of PE - 0.05% of all pregnancies
Treatment options should take the
following into consideration:
(1) the safety of the drug for both the fetus
and mother
(2) the efficacy of the regimen
(3) dose regimens for acute and secondary
treatment and during delivery and after
childbirth.
Venous Thromboembolism
Patients can be effectively treated with
Heparin or LMWH.

Warfarin should only be used in the 2
nd

trimester or during the postpartum period.

Heparin and LMWH should be discontinued
24 hours prior to elective induction of
labor to avoid an unwanted anticoagulant
effect during delivery.
Venous Thromboembolism
Postpartum heparin therapy should
be restarted within 12 hours of
delivery.

Warfarin can be started at the same
time with a goal INR of 2.0 or
greater.
Venous Thromboembolism
Anticoagulants should be given for at least
4 weeks following delivery.

If the DVT or PE was diagnosed during
pregnancy, anticoagulants should be
continued for a minimum of 3 months.

Inferior vena cava filters are indicated in
patients with a contraindication to
anticoagulants.
Antiphospholipid Syndrome
Presence of 2 autoantibodies, lupus antioagulant
and anticardiolopin antibody
Patients are at risk for venous and arterial
thrombotic events
Mechanism is unknown but related to enhanced
platelet activity, inhibition of protein C and
elevated factor VIII activity
Fetus at high risk for death in utero due to
placental infarction
Studies have showed improved fetal outcome
when affected pregnant women are treated with
prednisone, heparin or aspirin.
Guidelines for Regional Anesthesia
while on Anticoagulation
Subcutaneous Heparin
Intravenous Heparin
Low Molecular Weight Heparin
Coumadin
Antiplatelet Medications


Subcutaneous Heparin
During administration of
subcutaneous heparin, there is no
contraindication to neuroaxial
techniques

For patients receiving mini dose
heparin for 4 days, reassess
platelet count prior to neuroaxial
block or removal of catheter.
Intravenous Heparin
Should be avoided in patients with
concomitant coagulopathies

Heparin administration should be
delayed for 1 hour after needle
placement
Intravenous Heparin
Indwelling neuraxial catheters should
be removed 2-4 hours after the last
heparin dose and reevaluation of the
patient's coagulation status has
occurred.

Re-heparinization should occur one
hour after catheter removal.

Low-Molecular Weight Heparin (LMWH)
Monitoring of anti-Xa level is not
recommended as it is not predictive of the
risk of bleeding.

Antiplatelet or oral anticoagulant medications
administered in combination with LMWH may
increase the risk of spinal hematoma.

Traumatic needle or catheter placement may
signify an increased risk of spinal hematoma
and initiation of LMWH therapy in this setting
should be delayed for 24 hours.
Low-Molecular Weight Heparin (LMWH)
In patients receiving LMWH for DVT
prophylaxis prior to surgery, needle
placement should be delayed at least
10-12 hours after the administration
of LMWH.

Low-Molecular Weight Heparin (LMWH)
In patients receiving higher doses of
LMWH (1 mg/kg every 12 hours or
1.5 mg/kg daily), needle insertion
should be delayed for 24 hours.

Low-Molecular Weight Heparin (LMWH)
Twice daily dosing
The first dose of LMWH should be started no
earlier than 24 hours postoperatively and
surgical hemostasis has been achieved.

Indwelling catheters should be removed prior to
initiation of LMWH thromboprophylaxis.

If a continuous technique is selected, the
epidural catheter may be left indwelling
overnight and removed the following day, with
initiation of LMWH occurring at least two hours
after catheter removal.
Low-Molecular Weight Heparin (LMWH)
Single daily dosing
The first postoperative LMWH dose should
be administered 6-8 hours postoperatively
and the second dose should be given at
least 24 hours after the first dose.

Indwelling catheter should be removed at
least 10-12 hours after the last dose of
LMWH.

Further LMWH dosing should occur 2
hours after catheter removal.
Warfarin
In patients receiving chronic
anticoagulation, warfarin should be
discontinued at least 4-5 days before
procedure.

The PT/INR should be evaluated prior to
any neuroaxial technique.

In patients with an epidural receiving low
dose warfarin therapy, the PT/INR should
be monitored on a daily basis, and
checked before catheter removal.
Warfarin
Indwelling catheters can be removed
when the INR is less 1.5

In patients with an INR >3, the warfarin
dose should be held or decreased.
No definitive recommendation for removal of
neuraxial catheters in patients with therapeutic
levels of anticoagulation.

Neurologic testing should be performed
routinely during epidural analgesia and
should be continued after catheter
removal for at least 24 hours.
Antiplatelet Medications
NSAIDs,
Thienopyridine derivatives
Ticlopidine and Clopidogrel
Platelet GP IIb/IIIa antagonists
Abciximab, Eptifibatide and Tirofiban

Antiplatelet Medications
NSAIDs do not represent added significant
risk for the development of spinal
hematoma in patients having epidural or
spinal anesthesia.

The actual risk of spinal hematoma with
ticlopidine and clopidogrel and the GP
IIb/IIIa antagonists is unknown
The suggested time interval between
discontinuation of thienopyridine therapy and
neuraxial blockade is 14 days for ticlopidine
and 7 days for clopidogrel.
Antiplatelet Medications
GP IIb/IIIa inhibitors exert a profound
effect on platelet aggregation.

Platelet aggregation returns to normal
after 24-48 hours for abciximab and 4-8
hours for eptifibatide and tirofiban.

Neuraxial techniques should be avoided
until platelet function has recovered.
Conclusions
The decision to perform spinal or epidural
anesthesia/analgesia and the timing of
catheter removal in a patient receiving
anticoagulation should be made on an
individual basis.

The patient's coagulation status should be
optimized at the time of spinal or epidural
needle/catheter placement.

Conclusions
The level of anticoagulation must be
carefully monitored during the period
of epidural catheterization.

Indwelling catheters should not be
removed in the presence of
therapeutic anticoagulation.