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CASE PRESENTATION: INDIVIDUALISED DECISION-MAKING BASED ON THROMBOELASTOGRAPHY IN A PATIENT WITH INHERITED HYPOFIBRINOGENAEMIA
Author(s): ,
Eden-Green, B.*
Affiliations:
Queen Victoria Hospital, Department of Anaesthesia and Critical Care, East Grinstead, United Kingdom
Fleming, I.
Affiliations:
King's College Hospital, Department of Anaesthesia, London, United Kingdom
ESRA Academy. Eden-Green B. Sep 13, 2017; 190822
Topic: Obstetric Population
Disclosure(s): Nothing to declare
Dr. Ben Eden-Green
Dr. Ben Eden-Green

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Abstract
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Background and Aims:

Inherited hypofibrinogenaemia is a very rare disorder, with a prevalence of 0.5-3 per million. Regional anaesthesia is considered to be contraindicated due to the increased risk of epidural haematoma. This case demonstrates how point of care coagulation testing was used to challenge this orthodoxy. It is also the first case reported on the use of epidural analgesia in a patient with hypofibrinogenaemia.

Methods:

A 41 year old primiparous woman presented to the delivery suite for induction of labour (indication post-dates). She had a diagnosis of inherited hypofibrinogenaemia (clauss fibrinogen 0.4g/L pre-pregnancy).  She had been reviewed 1 month earlier in the anaesthetic pre-assessment clinic and following discussion with her haematology team it was agreed that regional anaesthesia was contraindicated.

After a long first stage of labour, where opioid analgesia was insufficient, she requested a caesarean section on the grounds of uncontrolled pain.  Thromboelastography (TEG) was performed (see Figures 1 and 2). These results were discussed with Haematology and the patient and it was agreed that epidural analgesia could be safely offered. She proceeded to have a normal vaginal delivery under epidural analgesia.

Results:

Figure 1. Thromboelastogram (Kaolin) at time of decision to site epidural.


Figure 2. Thromboelastogram (functional fibrinogen) at time of decision to site epidural.

Conclusions:

Through use of point of care coagulation testing, the anaesthetic team was able to demonstrate to themselves, Haematology and the patient, that the patient’s clotting was adequate.  Thromboelastography thus enabled a rapid response to the clinical situation, a change to the original anaesthetic plan, and a normal delivery.

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