From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts.
Department of Anesthesia, Stanford University School of Medicine, Stanford, California.
Anesth Analg. 2018 Mar;126(3):928-944. doi: 10.1213/ANE.0000000000002530.
Venous thromboembolism is recognized as a leading cause of maternal death in the United States. Thromboprophylaxis has been highlighted as a key preventive measure to reduce venous thromboembolism-related maternal deaths. However, the expanded use of thromboprophylaxis in obstetrics will have a major impact on the use and timing of neuraxial analgesia and anesthesia for women undergoing vaginal or cesarean delivery and other obstetric surgeries. Experts from the Society of Obstetric Anesthesia and Perinatology, the American Society of Regional Anesthesia, and hematology have collaborated to develop this comprehensive, pregnancy-specific consensus statement on neuraxial procedures in obstetric patients receiving thromboprophylaxis or higher dose anticoagulants. To date, none of the existing anesthesia societies' recommendations have weighed the potential risks of neuraxial procedures in the presence of thromboprophylaxis, with the competing risks of general anesthesia with a potentially difficult airway, or maternal or fetal harm from avoidance or delayed neuraxial anesthesia. Furthermore, existing guidelines have not integrated the pharmacokinetics and pharmacodynamics of anticoagulants in the obstetric population. The goal of this consensus statement is to provide a practical guide of how to appropriately identify, prepare, and manage pregnant women receiving thromboprophylaxis or higher dose anticoagulants during the ante-, intra-, and postpartum periods. The tactics to facilitate multidisciplinary communication, evidence-based pharmacokinetic and spinal epidural hematoma data, and Decision Aids should help inform risk-benefit discussions with patients and facilitate shared decision making.
静脉血栓栓塞症被认为是美国产妇死亡的主要原因。血栓预防已被强调为减少与静脉血栓栓塞相关的产妇死亡的关键预防措施。然而，在产科中扩大使用血栓预防措施将对接受阴道或剖宫产分娩和其他产科手术的女性使用和时机产生重大影响神经轴麻醉和镇痛。来自产科麻醉和围产医学学会、美国区域麻醉学会和血液学专家合作制定了这份全面的、针对接受血栓预防或更高剂量抗凝剂的产科患者的神经轴程序妊娠特异性共识声明。迄今为止，没有一个现有的麻醉学会的建议权衡了存在血栓预防措施时神经轴程序的潜在风险，存在潜在困难气道的全身麻醉的竞争风险，或避免或延迟神经轴麻醉对母亲或胎儿的伤害。此外，现有的指南没有整合抗凝剂在产科人群中的药代动力学和药效动力学。本共识声明的目的是提供一个实用指南，说明如何在产前、产中和产后期间适当识别、准备和管理接受血栓预防或更高剂量抗凝剂的孕妇。促进多学科沟通的策略、基于证据的药代动力学和脊柱硬膜外血肿数据以及决策辅助工具应该有助于与患者进行风险效益讨论，并促进共同决策。
