SOAP Interdisciplinary Consensus Statement on Neuraxial Procedures in Obstetric Patients with Thrombocytopenia

Because up to 12% of obstetric patients meet criteria for the diagnosis of thrombocytopenia in
pregnancy, it is not infrequent that the anesthesiologist must decide whether to proceed with a
neuraxial procedure in an affected patient. Given the potential morbidity associated with general
anesthesia for cesarean delivery, thoughtful consideration of which patients with thrombocytopenia
are likely to have an increased risk of spinal epidural hematoma with neuraxial procedures, and
when these risks outweigh the relative benefits is important to consider and to inform shared decision
making with patients. Because there are substantial risks associated with withholding a neuraxial
analgesic/anesthetic procedure in obstetric patients, every effort should be made to perform
a bleeding history assessment and determine the thrombocytopenia etiology before admission for
delivery. Whereas multiple other professional societies (obstetric, interventional pain, and hematologic)
have published guidelines addressing platelet thresholds for safe neuraxial procedures,
the US anesthesia professional societies have been silent on this topic. Despite a paucity of
high-quality data, there are now meta-analyses that provide better estimations of risks. An interdisciplinary
taskforce was convened to unite the relevant professional societies, synthesize the
data, and provide a practical decision algorithm to help inform risk-benefit discussions and shared
decision making with patients. Through a systematic review and modified Delphi process, the taskforce
concluded that the best available evidence indicates the risk of spinal epidural hematoma
associated with a platelet count ≥70,000 × 106/L is likely to be very low in obstetric patients with
thrombocytopenia secondary to gestational thrombocytopenia, immune thrombocytopenia (ITP),
and hypertensive disorders of pregnancy in the absence of other risk factors. Ultimately, the decision
of whether to proceed with a neuraxial procedure in an obstetric patient with thrombocytopenia
occurs within a clinical context. Potentially relevant factors include, but are not limited to, patient
comorbidities, obstetric risk factors, airway examination, available airway equipment, risk of general
anesthesia, and patient preference. Endorsed by the American Society of Regional Anesthesia
and Pain Medicine (ASRA), American College of Obstetricians and Gynecologists (ACOG), and
the Society for Maternal-Fetal Medicine (SMFM).