Neuraxial Analgesia in Pregnant Individuals with Bleeding Disorders: A Comprehensive Examination of Obstetric Anesthesia Practices and Outcomes

Introduction: Neuraxial analgesia in obstetric anesthesia offers multiple advantages when compared with general anesthesia, including better pain relief and patient satisfaction, reduced opioid-related side effects, and decreased maternal morbidity and mortality. However, neuraxial analgesia carries a risk of hematoma, which can lead to permanent neurological complications, and is considered contraindicated in patients with uncorrected bleeding disorders. Hemostatic thresholds for safe neuraxial analgesia remain undetermined. Current evidence for neuraxial analgesia in pregnant individuals with bleeding disorders is limited to a few case reports or small case series, leaving significant gaps in clinical practices based on expert opinions. We sought to examine obstetric analgesia practices and outcomes in pregnant individuals with bleeding disorders. Specifically, we aimed to determine the methods used at the time of labor and delivery, the concordance with antenatal recommendations, and the outcomes in relation to the bleeding disorder, hemostatic thresholds, and hemostatic therapy support. Methods: A retrospective cohort study was conducted on all pregnant individuals with bleeding disorders who delivered between 2010-2020 at our institution, a large tertiary academic care center with high-risk obstetrical care in Ontario, Canada. We collected data on patient and disease characteristics, delivery mode, hemostatic laboratory values, hemostatic support, obstetric analgesia method, antenatal anesthesia and hematology recommendations, and post-procedure outcomes. A descriptive analysis was performed to present the findings. Results: The study cohort comprised of 56 pregnant patients, resulting in 82 deliveries. The median maternal age was 31.5 years (interquartile range (IQR): 28-34), and the median gestational age was 39 weeks (IQR: 38-40). Most patients delivered vaginally (60/82, 73.2%). von Willebrand disease type 1 (VWD-1) (28/82, 34.1%) and hemophilia A (24/82, 29.3%) were the most prevalent bleeding disorders. Neuraxial analgesia was used in most deliveries (59/82, 72.0%), followed by opioids (25/82, 30.5%), and nitrous oxide (15/82, 18.3%). Antenatal neuraxial anesthesia recommendations were documented by anesthesiology in 59.8% (50/82) and by hematology in 82.9% (68/82) of deliveries. The concordance rate between the two specialties was high at 95.7%. In two cases with discordant recommendations, neuraxial anesthesia was performed without hemostatic therapy, and no adverse events were reported. A diagnosis of bleeding disorder was established prior to the pregnancy in 79 deliveries (96.3%). Three patients were diagnosed after pregnancy: one with VWD-1 and baseline von Willebrand factor (VWF) activity at 0.34 IU/mL, one with VWD-1 and baseline VWF activity at 0.44 IU/mL, and one with Factor XIII deficiency and baseline levels at 0.42 IU/mL. They had neuraxial anesthesia administered without bleeding complications. Hemostasis laboratory values in the third trimester were considered adequate for neuraxial analgesia in 68.4% (54/79) of deliveries. Those who did not reach adequate levels received hemostatic therapy support prior to neuraxial analgesia, except for three patients (one with VWD-1 with VWF activity < 0.50 IU/mL, one with VWD type 2 with VWF activity < 0.50 IU/mL, one with factor XI deficiency and levels < 0.40 IU/mL) who fortunately did not develop post-procedural hematomas. We observed no bleeding events following neuraxial analgesia, but there were two adverse events (pain at epidural site) necessitating emergency room visits. Conclusions: Our study represents the largest cohort of pregnant individuals with bleeding disorders receiving neuraxial anesthesia and provides evidence supporting the safe administration of neuraxial analgesia, with high level of adherence to antenatal recommendations. In most cases, hemostatic laboratory values were deemed adequate, obviating the need for additional hemostatic therapy support. These findings contribute to our understanding of obstetric anesthesia practices in this population, thereby facilitating the provision of safe and effective analgesia during labor and delivery. Future prospective and multicenter studies focusing on the obstetrical management of pregnant persons with bleeding disorders, with specific emphasis on neuraxial analgesia, are warranted.

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