Indication for spinal anesthesia for cesarean section in HELLP syndrome coagulopathy

We describe the relation between coagulation and local-regional anesthesia in two women with HELLP syndrome who required emergency cesarean delivery. HELLP syndrome involves hemolysis, elevated liver enzyme levels and thrombopenia complicating the hypertension of pregnancy. Regional anesthesia presents advantages for mother and fetus in this context but also involves the risk of coagulopathy. In the first case we describe, coagulation was normal before surgery and epidural anesthesia was therefore prescribed. The initial epidural puncture was hemorrhagic and a second, higher puncture was made to insert the catheter. Shortly after surgery severe thrombopenia developed and lasted 24 hours; formation of an epidural hematoma caused by vascular lesion during puncture was suspected. The epidural catheter was left in place, and the patient was kept under observation and seen by a neurologist within the first 48 hours. Outcome was good. In the second patient, epidural puncture was contraindicated by the presence of preoperative coagulopathy, and the cesarean was performed without complications under intradural anesthesia provided with low doses of bupivacaine and fentanyl. The coagulopathy that accompanies HELLP syndrome should be assessed not only before taking the decision on anesthetic technique; as the condition can be progressive it can become most severe after the epidural puncture is performed, as shown by the first case we describe. The patient's condition must be watched closely until coagulation becomes normal. Removal of the epidural catheter must wait until coagulopathy is resolved. When coagulopathy is evident before surgery, intradural anesthesia is a safe option provided hemodynamic stability is assured, as demonstrated by the second case we report.