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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 12  |  Issue : 1  |  Page : 67-69

Spinal anaesthesia, a special consideration in antiphospholipid antibody syndrome in pregnancy: A case series


Department of Anaesthesiology, IMS and SUM Hospital, SOA Deemed to be University, Bhubaneswar, Odisha, India

Date of Submission26-Aug-2021
Date of Acceptance15-Nov-2021
Date of Web Publication14-Mar-2022

Correspondence Address:
Dr. Soumya Samal
Department of Anaesthesiology, IMS and SUM Hospital, SOA Deemed to be University, Bhubaneswar - 751 003, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JOACC.JOACC_74_21

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  Abstract 


Antiphospholipid syndrome (APLA) is an acquired autoimmune disorder, clinically characterised by the development of thrombosis and obstetric morbidities comprising recurrent miscarriages, fetal deaths and premature births resulting from placental insufficiency such as intrauterine growth restriction and pre-eclampsia. It is the most common acquired hypercoagulable state where the focus of management is anticoagulation for the prevention of thrombosis.We report three cases of primary APLA syndrome in parturients at term with history of multiple abortions, being managed with oral aspirin and low molecular weight heparin posted for elective caesarian section. All three parturients were given single shot atraumatic spinal anaesthesia achieving a level of sensory blockade up to T6 since their coagulation profile showed no abnormalities. Antiphospholipid-antibody syndrome requires a multidisciplinary approach during pregnancy where use of anticoagulants may lead to dilemma of their perioperative continuation. Discontinuation of anticoagulants is a double-edged sword requiring careful deliberation on the part of anaesthetist to reduce the risk of perioperative bleeding.

Keywords: Antiphospholipid antibody syndrome, pregnancy, spinal anaesthesia


How to cite this article:
Banerjee E, Samanta S, Samal S. Spinal anaesthesia, a special consideration in antiphospholipid antibody syndrome in pregnancy: A case series. J Obstet Anaesth Crit Care 2022;12:67-9

How to cite this URL:
Banerjee E, Samanta S, Samal S. Spinal anaesthesia, a special consideration in antiphospholipid antibody syndrome in pregnancy: A case series. J Obstet Anaesth Crit Care [serial online] 2022 [cited 2022 Dec 9];12:67-9. Available from: https://www.joacc.com/text.asp?2022/12/1/67/339549




  Introduction Top


Antiphospholipid antibody (APLA) syndrome is an acquired autoimmune hypercoagulable disorder caused by the presence of antiphospholipid antibodies. It is characterised by thrombotic episodes in arteries, veins and pregnancy related complications like recurrent miscarriages, fetal deaths and premature births resulting from placental insufficiency such as intrauterine growth restriction and pre-eclampsia.[1] Here we are reporting three case reports of primary APLA syndrome in pregnancy posted for lower segment caesarean section which was conducted with single shot atraumatic spinal anaesthesia.

Case Histories

First case is a 32-year-old woman with history of two previous abortions and a positive serology for lupus anticoagulant and increase in anti-phospholipid antibodies (APLA) - 16.32 U/ml with laboratory reference of 12 U/ml came to our hospital at 37 weeks and four days for safe confinement. She was a known case of Type 2 diabetes mellitus on Insulin for glycemic control for past one year. The second case was a 28-year-old woman with body mass index of 40.1 kg/m2 and history of two previous abortions and a positive serology for lupus anticoagulant and increase in anti-phospholipid antibodies (17.02 U/ml) at 38 weeks and 2 days for safe confinement. Above two cases were started on aspirin 75 mg once daily (OD) and injection enoxaparin 60 mg subcutaneously to improve overall fetal outcome. Injection enoxaparin was stopped 12 h before the planned surgery and started after 24 h postoperatively for 6 weeks along with aspirin 75 mg.

The third case was a 30-year-old woman with history of three previous abortions and APLA was 19.46 U/ml came to our hospital at 37 weeks for safe confinement. She was started on aspirin 75 mg OD and injection nadroparin 0.3 ml (9500 IU/ml) subcutaneously to improve overall fetal outcome. Injection nardroparin was stopped 24 h before the planned surgery. Patient was started on injection nadroparin after 24 h postoperatively for 6 weeks along with aspirin 75 mg.

In view of poor obstetric history, an elective lower section caesarean section was planned in all the three cases. Preoperative investigations revealed a normal prothrombin time, activated partial thromboplastin time and international normalized ratio. All the patients were premedicated with injection ondansetron 8 mg, injection pantoprazole 40 mg and injection metaclopromide 10 mg was given 1 h before the start of the surgery. Single shot atraumatic spinal anaesthesia was given in the L3--L4 intervertebral space with a 25G Quincke's needle in midline approach with patient in left lateral position after preloading with 500 ml crystalloids and drug used was 2.2 ml of 0.5% heavy bupivacaine along with 100 μg of morphine. The intraoperative period remained uneventful with an average bleeding of 800 ml for all the 3 cases. Three of them delivered single live child with good APGAR score. Postoperatively the patients didn't show any signs of excess bleeding or thrombotic episodes and were discharged on the third day post delivery.


  Discussion Top


Antiphospholipid antibody syndrome being an autoimmune disorder having varied symptomatology ranging from recurrent episodes of thromboembolism, multiple abortions, thrombocytopenia and hemolytic anemia.[1],[2] The diagnosis of the antiphospholipid syndrome is primarily based on the clinical presentation and evidence of positive serology for APLAs where Lupus anticoagulant, anticardiolipin and anti-β2 glycoprotein are the most commonly associated antibodies. Clinical presentation of this syndrome happens in only 2% of the population though the APLAs can be present in about 5% of the population.[3] It can be primary in the absence of any underlying illness or secondary when associated with other autoimmune disorders.[2]

APLA syndrome is hallmarked with obstetric complications such as recurrent miscarriage, early delivery, oligohydramnios, prematurity, intrauterine growth restriction, fetal distress, fetal or neonatal thrombosis, pre-eclampsia/eclampsia, HELLP syndrome, arterial or venous thrombosis and placental insufficiency are the most severe APS-related complication for pregnant women.[4] Although numerous pathophysiological mechanisms have been put forward, the most acceptable one is that, antiphospholipid antibodies promote activation of endothelial cells, monocytes and platelets, causing an overproduction of tissue factor and thromboxane A2. These factors, along with the typical changes in the hemostatic system during normal pregnancy, results in a hypercoagulable state which is responsible for thrombosis that is presumed to provoke many of the pregnancy complications associated with APS. Obstetric care is based on combined medical-obstetric high-risk management and treatment with the association between aspirin and heparin. This therapy is withheld at the time of any elective surgery to decrease risks of intraoperative bleeding and restarted and continued for 6 weeks into the postpartum period[5],[6] The risk of thrombosis when the patient is not effectively anticoagulated, must be weighed against the risk of bleeding during and after surgery, if anticoagulation in continued peri-operatively. Intraoperatively, to prevent thrombosis certain physical measure as in anti-embolic stockings, intermittent venous compression devices and adequate hydration are advised.[7]

Patients with APLA Syndrome require special consideration for perioperative management as a result of the disease process itself along with ongoing anticoagulation therapy. The choice of anaesthesia for such patient remains at the discretion of the anesthesiologist and the coagulation profile, and whether to proceed with neuraxial block or general anesthesia remains a challenge to make. Manipulation of airway in pregnancy comes with its own set of problems: airway edema, increased tissue friability, consideration of full stomach, thus posing a challenge of its own. Most of the literature available overshadowed the used of regional techniques for general anaesthesia keeping the risks of deranged coagulation profile and possible thrombocytopenia in mind. But Ringrose[8] in his case series conducted on 20 women concluded that, “ In the absence of coagulation defects secondary to clotting factor antibodies or platelet abnormalities, the in vitro phenomenon of prolonged aPTT alone should not, in theory, predispose to haemorrhage or be a contradiction to epidural anaesthesia in patients with APLAS”. Sometimes, antiphospholipid reacts with serum protein beta-2 glycoprotein 1 and the phospholipid complex that is normally responsible for inhibiting factor XII activation/platelet activation, leading to an increase in the PTT. Rarely, there may be antibodies to the clotting factors II, VII, VIII and IX, which can also prolong the PTT tests.[9]

We proceeded with single-shot atraumatic spinal anaesthesia with 25 G Quinckes needle in all our patients posted for elective Caesarian section because all patients had a normal coagulation profile with no thrombocytopenia. As per recommendation, low molecular heparin was stopped 12 h before any elective surgical procedure and restarted 6--8 h afterwards. The intraoperative period remained uneventful with an average bleeding of 800 ml for all the 3 cases. The choice for general anaesthesia was kept at bay considering the risks associated with handling airway in obstetric population.


  Conclusion Top


APLA syndrome requires a multidisciplinary approach during pregnancy where use of anticoagulants may lead to dilemma of their perioperative continuation. Discontinuation of anticoagulants is a double-edged sword requiring careful deliberation on the part of anaesthetist to reduce the risk of perioperative bleeding. Decision to give general anaesthesia or neuraxial block is the sole choice of the anaesthetist. The benefits of giving spinal anaesthesia in the setting of a normal coagulation profile outweighed the risks of airway handling in partiurents.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shapiro SS, Thiagarajan P. Lupus anticoagulants. Prog Hemost Thromb 1982;6:263-85.  Back to cited text no. 1
    
2.
Dhir V, Pinto B. Antiphospholipid syndrome: A review. J Mahatma Gandhi Inst Med Sci 2014;19:19-27.  Back to cited text no. 2
  [Full text]  
3.
Mikkiliineni VR, Panidapu N, Parasa M, Shaik MS. Anesthetic management in a case of antiphospholipid antibody syndrome. Anesth Essays Res 2015;9:411-2.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Pierangeli SS, Colden-Stanfield M, Liu X, Barker JH, Anderson GL, Harris EN. Antiphospholipid antibodies from antiphospholipid syndrome patients activate endothelial cells in vitro and in vivo. Circulation 1999;99:1997-2002.  Back to cited text no. 4
    
5.
Brooker G, Ralph C. Thromboprophylaxis for patients with antiphospholipid syndrome during their pregnancy. Int. J Obstet Anesth 2004;13:129-30.  Back to cited text no. 5
    
6.
Dersken RH, Khamashta MA, Branch DW. Management of the obstetric antiphospholipid syndrome. Arthritis Rheum 2004;50:1028-39.  Back to cited text no. 6
    
7.
Menon G, Allt Graham J. Anaesthetic implications of the anti-cardio lip in antibody syndrome. Br J Anaesth1993;70:587-90.  Back to cited text no. 7
    
8.
Ringrose DK. Anaesthesia and the antiphospholipid syndrome: A review of 20 obstetric patients. Int J ObstetAneasth 1999;8:249-52.  Back to cited text no. 8
    
9.
Birdsall MA, Pattison NS. Antiphospholipid antibodies in pregnancy: Clinical associations. Br J Hosp Med 1993;50:251-60.  Back to cited text no. 9
    




 

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