Coagulation testing before epidural analgesia at delivery: cost analysis.

Area of Science:

• Obstetrics and Gynecology
• Anesthesiology
• Hematology

Background:

• The utility of pre-procedure coagulation tests for epidural analgesia in labor or surgery is debated.
• Prevalence of abnormal coagulation tests and association with epidural hematoma in pregnant women is not well-established.

Purpose of the Study:

• To determine the prevalence of abnormal coagulation tests in healthy pregnant women.
• To assess anesthesiologists' management of women with abnormal coagulation results.
• To evaluate the economic impact of universal coagulation screening before epidural analgesia.

Main Methods:

• Retrospective chart review of pregnant women undergoing epidural analgesia.
• Analysis of data on epidural hematoma, prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen, and platelet count.
• Cost-effectiveness analysis based on literature data for epidural hematoma incidence.

Main Results:

• No cases of epidural hematoma were observed in 2546 women receiving epidural analgesia.
• Low prevalence of abnormal coagulation tests: prolonged PT (0.1%), prolonged APTT (0.14%), low platelets (0.53%), low fibrinogen (0.91%).
• Anesthesiologists rarely altered practice unless platelets were <80 × 10(9)/L; screening costs to prevent one hematoma range from 4.5 to 40 million Euros.

Conclusions:

• Universal, unselected coagulation screening before epidural analgesia in healthy pregnant women is not advisable.
• The extremely low incidence of epidural hematoma does not justify the high cost of widespread screening.
• Current guidelines should reconsider routine coagulation testing in this population.