title: Anticoagulant and antithrombotic drugs in pregnancy: what are the anesthetic implications for labor and cesarean delivery?
abstract: Neuraxial anesthetic techniques are commonly used during the peripartum period to provide effective pain relief for labor and anesthesia during cesarean delivery. Major neurologic complications are rare after neuraxial anesthesia; however, spinal hematoma is associated with catastrophic neurologic outcomes (including lower-limb paralysis). Anticoagulant and antithrombotic drugs can increase the risk of spinal hematoma after neuraxial anesthesia, and better understanding of the pharmacokinetics and pharmacodynamics of anticoagulants has led to greater appreciation for withholding anticoagulation before and after neuraxial anesthesia. A number of national anesthetic societies have produced guidelines for performing neuraxial anesthesia in patients receiving anticoagulation. However, there is limited information about anesthetic implications of anticoagulation during the peripartum period. This article will review the risks of spinal hematoma after neuraxial anesthesia in pregnant patients; current guidelines for neuraxial anesthesia for anticoagulated patients; and relevant pharmacological data of specific anticoagulant and antithrombotic drugs in pregnancy.
authors.affiliation: Department of Anesthesiology, Stanford University School of Medicine, Stanford, CA 94305, USA. ajbut@stanford.edu
authors.forename: A J
authors.initials: AJ
authors.lastname: Butwick
authors.forename: B
authors.initials: B
authors.lastname: Carvalho
mesh_terms: D000765:Anesthesia, Conduction / Q000009:adverse effects* / Q000379:methods; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects*; D001779:Blood Coagulation Factors / Q000187:drug effects*; D036861:Delivery, Obstetric / Q000009:adverse effects* / Q000379:methods; D004334:Drug Administration Schedule; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000009:adverse effects*; D017408:Guidelines as Topic; D046649:Hematoma, Subdural, Spinal / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D006801:Humans; D008991:Monitoring, Physiologic; D058725:Peripartum Period / Q000378:metabolism; D011247:Pregnancy; D011249:Pregnancy Complications, Cardiovascular / Q000097:blood / Q000188:drug therapy; D020379:Risk Adjustment
chemical_list: D000925:Anticoagulants; D001779:Blood Coagulation Factors; D005343:Fibrinolytic Agents