Optimizing the anesthetic management of factor XI deficiency in obstetrics: A case report using ROTEM

Factor XI (FXI) deficiency is a rare coagulation disorder with poor correlation between FXI levels and bleeding risk, posing challenges in obstetric anesthesia. Neuraxial anesthesia is often avoided due to theoretical concerns about spinal hematoma. However, viscoelastic testing such as rotational thromboelastometry (ROTEM) may offer functional insights into coagulation status.

We report the case of a 28-year-old primigravid woman with an incidentally discovered moderate FXI deficiency (52.6 %) during routine preoperative evaluation for suspected macrosomia. The patient had a minimal bleeding history (ISTH-BAT score: 1). ROTEM (INTEM assay) showed mildly prolonged clotting time (CT: 236 s) and slightly reduced early clot firmness (A5: 42 mm), with preserved maximum clot firmness (MCF: 68 mm). Given the integrative evaluation-moderate FXI deficiency, reassuring ROTEM profile, and absence of bleeding symptoms-spinal anesthesia was safely performed under prophylactic tranexamic acid. The elective Cesarean section was uneventful, with estimated blood loss of 450 mL and no hemostatic complications.

This case illustrates how ROTEM, although not diagnostic alone, can support multidisciplinary decision-making in obstetric anesthesia for FXI-deficient patients. The postoperative ROTEM improvement was likely multifactorial, including postpartum procoagulant shift and TXA use, rather than a direct effect of ROTEM-guided intervention.

ROTEM may serve as a useful adjunct in the individualized management of FXI deficiency during pregnancy. However, its role remains complementary, and further prospective studies are needed to clarify its predictive value and establish standardized thresholds.