The incidence of coagulopathy in pregnant patients with intrahepatic cholestasis: should we delay or avoid neuraxial analgesia?

Abstract

Study Objective

To estimate the incidence of coagulopathy in patients with intrahepatic cholestasis inhepatic cholestasis of pregnancy (ICP).

Design

Retrospective cohort investigation.

Setting

University medical center.

Measurements

The records of 319 parturients who met study inclusion criteria were reviewed for various laboratory values. The primary outcome was the incidence of abnormal hemostasis, defined as prothrombin time (PT) greater than 14.5 seconds (INR > 1.2). The incidence of postpartum hemorrhage was evaluated as a secondary outcome.

Main Results

The incidence (95% CI) of abnormal PT was 0% (0 to 1.8). Other coagulation tests [partial thromboplastin time (PTT) and platelet count] were also normal, even in study subjects with significant (> 5 times) elevation of liver enzymes. The incidence of postpartum hemorrhage after vaginal delivery was 2.4% (4 of 208 pts) and 6.3% (7 of 111 pts) after Cesarean delivery.

Conclusions

Coagulation abnormalities are rare in pregnant patients with ICP, even when a strict criterion is utilized (INR < 1.2). The use of neuraxial anesthesia and/or analgesia may not necessarily be delayed in parturients with isolated ICP.

Introduction

Many women request analgesia for labor or require surgical anesthesia for Cesarean delivery [1], [2]. The American College of Obstetricians and Gynecologists has stated that neuraxial analgesia is the most flexible, effective, and least depressing analgesic modality to the central nervous systems of both the mother and the baby [3]. Delaying neuraxial analgesia may cause significant patient distress and suffering, especially when optimal analgesia is not achieved with systemic medications or other regional techniques [4], [5], [6], [7]. Due to the risk for spinal-epidural hematoma, parturients with diseases that may potentially adversely affect hemostasis are frequently denied neuraxial analgesia until abnormal coagulation is excluded by laboratory examination. A coagulopathy is considered a contraindication to neuraxial procedures because of the potential catastrophic consequences of spinal-epidural hematomas [8], [9], [10].

Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disease unique to pregnancy, with a reported incidence as high as 4% [11]. Patients with ICP have steatorrhea from fat malabsorption, which may adversely affect vitamin K absorption and impair coagulation [12]. In addition, the disease may cause transient liver damage, which may further impair coagulation. Small studies (≤ 100 subjects) examined the incidence of coagulopathy, evaluated by a prolonged prothrombin time (PT) in women with ICP and showed conflicting results, but the incidence of abnormal coagulation tests has been as high as 20% [13], [14]. Since the incidence of coagulopathy in patients with ICP is currently not well defined, some practitioners often delay neuraxial techniques in those patients until laboratory exclusion of abnormal hemostasis is obtained.

The main objective of the current investigation was to estimate the incidence of coagulopathy in women with ICP and to determine if the presence of abnormal liver function in patients with ICP was associated with a higher incidence of abnormal coagulation tests.