• Liane J Bailey, Nadine Shehata, Bryon De France, Carvalho Jose C A JCA Department of Anesthesia, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada., and Ann Kinga Malinowski.
• Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Canada.
• Can J Anaesth. 2019 Nov 1; 66 (11): 1396-1414.

PurposePrimary immune thrombocytopenia (ITP) is an autoimmune condition affecting women of childbearing age that is characterized by diminished platelet quantity with preserved function. Although pregnant women with ITP are often denied obstetric neuraxial anesthesia (OBNA) with low platelet counts for fear of neuraxial hematoma, the true magnitude of neuraxial hematoma for ITP parturients is unknown. The aim of this systematic review and meta-analysis was to examine OBNA outcomes in ITP parturients with platelet counts below 100 x 109·L-1.SourceArticles published in MEDLINE, Embase, Web of Science, Scopus, Cochrane, and PubMed in process until May 14, 2018 were searched. Two reviewers independently screened 954 articles by title and abstract, reviewed 62 full-texts, extracted data, and assessed risk of bias for 26 articles.Principal FindingsOf 291 pregnant women with ITP and platelet counts below 100 x 109·L-1, 166 received OBNA and 61 of these had platelet counts below 80 x 109·L-1. No neuraxial hematomas were reported. Meta-analysis of six studies showed higher platelet counts in those with OBNA than without (mean difference [MD], 19 x 109·L-1; 95% confidence interval [CI], 11 to 26; P < 0.001), with no difference between epidural and spinal anesthesia (MD, 0.4 x 109·L-1; 95% CI, -4 to 4; P = 0.86).ConclusionOur study highlights continued reluctance to offer OBNA below the commonly quoted 80 x 109·L-1 platelet count, based largely on consensus and theoretical presumption of risk. This further negatively influences the accrual of large-scale data. The evidence of no neuraxial hematoma after OBNA provided herein offers support for considering neuraxial anesthesia at lower platelet count thresholds. Each patient should be afforded individualized discussion of risk and benefit relative to other analgesic measures.Trial RegistrationPROSPERO (CRD42018059220); registered 2 August, 2018.

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