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On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.54 no.1 Campinas Jan./Feb. 2004
Labor analgesia in protein S deficient patient. Case report*
Analgesia de parto en paciente portadora de deficiencia de proteína S. Relato de caso
Renato Mestriner Stocche, TSA, M.D.I; Luis Vicente Garcia, TSA, M.D. II; Marlene Paulino dos Reis, M.D.III; Jyrson Guilherme Klamt, TSA, M.D.II
IAssistente do Serviço de Anestesiologia
do HC da FMRP-USP
IIProfessor Assistente Doutor da Disciplina de Anestesiologia da FMRP-USP
IIIProfessora Associada da Disciplina de Anestesiologia da FMRP-USP
BACKGROUND AND OBJECTIVES: Deficiency
in protein S, which is a glycoprotein with anticoagulant activity, increases
the risk for thromboembolic events. This report aimed at addressing anesthetic
management of protein S deficient obstetric patient.
CASE REPORT: Protein S deficient patient, at 25 weeks gestation, presented the following lab results: INR = 0.9, TTPA = 32 s (control 25.6), protein S = 35% (normal = 70% to 130%). In the last three gestation quarters she has received up to 12,000 IU heparin every 8 hours. With 38 weeks, she was admitted in labor. After 8 uninterrupted heparin hours, already with TTPA of 25.8 s (control 27.8 s) epidural anesthesia was induced with 6 ml of 0.2% bupivacaine and fentanyl (20 µg), followed by continuous infusion. Infusion time was 5 hours with total 40 mg bupivacaine dose. There have been no intercurrences and 1 hour after catheter removal, subcutaneous 10,000 IU heparin were restarted at 12-hour intervals. Patient and neonate evolved well and were discharged 3 days later.
CONCLUSIONS: Protein S deficient pregnant patients should receive anticoagulants to maintain TTPA twice the control value. Heparin, for not crossing placental barrier, is the anticoagulant of choice in obstetrics. Blockade may be induced respecting a minimum period of 4 to 6 hours between last heparin dose and lumbar puncture, provided lab tests are within normal ranges. In these cases, however, epidural analgesia may help in preventing thromboembolic events.
Key Words: ANALGESIA, Obstetric: labor; ANESTHETIC TECHNIQUES, Regional: epidural; DISEASES: protein S deficiency
JUSTIFICATIVA Y OBJETIVOS: En la deficiencia
de proteína S, una glucoproteína con actividad anticoagulante,
el riesgo de eventos tromboembólicos está aumentado. El objetivo
de este relato es abordar el manoseo anestésico en paciente obstétrica
portadora de esta deficiencia.
RELATO DE CASO: Paciente con deficiencia de proteína S, con 25 semanas de gestación, presentó los siguientes resultados de exámenes: INR = 0,9, TTPA = 32 s (control 25,6), proteína S = 35% (normal = 70% a 130%). En los dos últimos trimestres de embarazo, hizo uso de hasta 12000 U de heparina, cada 8 horas. Con 38 semanas, fue internada en trabajo de parto. Pasadas 8 horas de la interrupción de la heparina, y ya con TTPA 25,8 s (control 27,8 s), se realizó anestesia peridural con inyección de 6 ml de bupivacaína a 0,2% y fentanil (20 µg), seguido de infusión continua. EL tiempo de infusión fue de 5 horas con dosis total de 40 mg de bupivacaína. No hubo intercurrencias y, 1 hora después de la retirada del catéter, fue reiniciada heparina, por vía subcutánea, 10.000 UI, a cada 12 horas. La madre y el recién nacido evoluyeron bien, recibiendo alta en el tercero día del pos-parto.
CONCLUSIONES: Embarazadas con deficiencia de proteína S deben recibir anticoagulantes con el objetivo de mantener el TTPA 2 veces el valor control. La heparina, por no atravesar a barrera placentaria, es el anticoagulante de elección en obstetricia. El bloqueo puede ser realizado respetando un tiempo mínimo entre cuatro a seis horas entre a última dosis de heparina y la realización de la punción lumbar, desde que los exámenes presenten parámetros de normalidad. Entretanto, en estos casos, la analgesia peridural puede auxiliar en la profilaxis de eventos tromboembólicos.
Protein S is a serum glycoprotein dependent on vitamin K, which acts as co-factor of protein C, which has anticoagulant activity 1. Protein C acts by inactivating coagulation cascade factors Va and VIIIa 2. This anticoagulant regulating effect presents as a physiological anti-thrombotic mechanism. So, protein S and/or protein C deficiency, are risk factors for thromboembolic events and are currently classified as thrombophilic diseases 3.
Protein S deficiency may be inherited, with pattern varying from genetic to acquired changes 4. Physiological states, such as pregnancy, may decrease plasma protein S levels 5. Several diseases have been related to this deficiency, such as multiple myeloma 6, HIV 7 and varicella 8 virus infection, systemic lupus erythematosus 9, and nephrotic syndrome 10, among others.
In general, young protein S deficient patients present with recurrent venous or arterial thrombosis without predisposing factors or in less common sites for their age 11-13. During pregnancy, there may be repetition abortion, abruption placenta, intra-uterine death and low gestational age weight, all related to multiple placental infarctions 14. Diagnosis is suspected through history of thromboembolic events, familial history or abrupt pregnancy interruption history 15. Confirmation is obtained by serum dosage 16.
This report aimed at addressing coagulation management, thromboembolism and spinal hematoma risks associated to labor analgesia technique in inherited protein S deficient patient.
Pregnant patient, 29 years old, with protein S deficiency diagnosed by clinical and lab exams 2 years after presenting lower limbs deep vein thrombosis.
As from the 25th week of gestation, patient was referred to the high risk and hematology outpatient department for follow up, when she presented the following lab results: PT = 0.9 seconds; INR = 0.9; TTPA = 32 seconds (control 26.6); TT = 8 seconds (control 9.5); Protein S = 35% (normal = 70% to 130%); Antithrombin III = 90% (normal = 70% to 130%); Fibrinogen = 290 mg/dl (normal = 200 to 400); Protein C = 73% (normal = 70% to 130%). As from beginning of prenatal follow-up, she received 10,000 to 12,000 IU subcutaneous heparin every 12 or 8 hours to maintain INR close to 2 (Table I). Hematological exams with hemoglobin and hematocrit count, among others, have remained within normal ranges throughout pregnancy and in the immediate post-delivery period.
Pregnancy has evolved without severe events and with controlled coagulopathy. Four ultrasounds were performed and have not evidenced fetal or placental abnormalities.
With 38 weeks and 6 days of amenorrhea, patient was admitted in labor with 4 cm dilatation and dynamic of 2 contractions in 10 minutes. After admission, the case was discussed with hematologist, anesthesiologist and obstetrician who decided to withdraw heparin and administer protamine if necessary. The option has been vaginal delivery with early delivery epidural analgesia. After previous activated coagulation time test resulting in 105 seconds and TTPA close to control (25.6 seconds) epidural puncture and catheter insertion were performed. Initial 6 ml of 0.2% bupivacaine associated to 20 µg fentanyl were administered followed by 0.2% bupivacaine and fentanyl (1 µg.ml-1) continuous infusion until second labor stage completion, with no need for additional doses. Delivery was helped by forceps 1 hour after total cervical dilatation. Total infusion time was 5 hours, with total 40 mg bupivacaine and 34 µg fentanyl doses. Epidural catheter was removed immediately after delivery and, 1 hour later, 10,000 IU subcutaneous heparin were restarted every 12 hours. Patient and neonate evolved without postoperative complications and were discharged 3 days after delivery.
Protein S deficiency associated to gestational hypercoagulability and labor stress highly increases the risk for intravascular thrombosis during pregnancy and in the peri-delivery period, thus requiring thromboembolism prophylaxis 14,15. Heparin poses less fetal risk as compared to cumarin agents and should be used throughout pregnancy and in the immediate post-delivery period. In our case, and according to the literature, TTPA was twice the control time 15. There is heparin action resistance during pregnancy and this was apparent in our case where heparin dose had to be increased and intervals decreased to maintain INR in 2 (Table I).
Vaginal delivery seems to be the method of choice because bleeding risk in C-section is higher, as well as stress and endocrine-metabolic and immune changes duration, which could result in increased risk for thrombotic events 15.
However, labor stress triggers neuroendocrine and metabolic response similar to surgical stress, resulting in hypothalamohypophysial axis activation and consequent hypercoagulability 17-19. So, anesthetic technique in this case should aim at maternal comfort and fetal wellbeing in addition to attenuating labor stress response. It is known that spinal analgesia is more effective in attenuating neuroendocrine and metabolic response to labor than systemic analgesia 20,21, justifying the choice of epidural analgesia with continuous infusion. Mechanisms by which spinal blocks modulate coagulation are not well defined; however other factors, different from neuroendocrine response decrease to maternal stress, are involved, including: increased blood flow in the blocked region 22, increase in fibrinolytic activity 23 via prevention of plasma plasminogen inhibiting factor increase 19 and decrease in platelet aggregation and blood viscosity. On the other hand, other factors involved in hypercoagulability, such as increased IL1, IL6 and tumor necrosis factor 24, are not influenced by current labor analgesic techniques.
Heparin should be withdrawn during labor because the risk for bleeding and hemorrhagic emergencies is increased. In general, neuraxis may be blocked respecting a minimum interval of 4 to 6 hours between last heparin dose and lumbar puncture, provided exams are within normal ranges. In our case, heparin was withdrawn 8 hours before epidural puncture, which was enough to normalize TTPA.
Initial bolus infusion followed by continuous infusion was the technique of choice to obtain deep and constant analgesia, decrease total anesthetic dose and labor stress response. Thromboembolism prophylaxis with heparin should be reintroduced in the post-delivery period; however, epidural catheter should be removed before starting prophylaxis because its removal may lead to epidural hematoma in patients receiving heparin. Studies have shown that heparin may be safely restarted one hour after epidural catheter insertion and it is possible that the same time interval should be respected for catheter removal 25.
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Submitted for publication March 10, 2003
Accepted for publication May 14, 2003
* Received from Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto (HCFMRP USP), Ribeirão Preto, SP