# Neuraxial analgesia in pregnant individuals with bleeding disorders: a retrospective descriptive study of obstetric anesthesia practices and outcomes

## TL;DR

This study shows that most pregnant individuals with bleeding disorders can safely receive neuraxial analgesia with proper planning and lab monitoring.

## Contribution

The study provides real-world evidence supporting the safe use of neuraxial analgesia in pregnant individuals with bleeding disorders.

## Key findings

- Neuraxial analgesia was used in 72% of deliveries among individuals with bleeding disorders.
- No epidural or spinal hematomas occurred despite some patients receiving analgesia below target hemostatic thresholds.
- High agreement (95.7%) was observed between anesthesiology and hematology recommendations.

## Abstract

Neuraxial analgesia is an effective and advantageous technique for managing labor pain. Yet, clinicians often hesitate to offer neuraxial analgesia to parturients with inherited bleeding disorders because of fear of epidural or spinal hematoma and the absence of high-quality evidence to guide decision-making in practice.

To describe obstetric analgesia practices and outcomes in pregnant individuals with bleeding disorders managed at a tertiary care center.

We performed a retrospective descriptive study of all deliveries (January 2010-July 2021) managed by the Ottawa Regional Bleeding Disorders Program. Patient, laboratory, peripartum anesthetic data, and antenatal anesthesia and hematology recommendations were collected from electronic health records and summarized descriptively.

Eighty-two deliveries occurred in 56 pregnant individuals (median age, 31 years). The most common disorders were type 1 von Willebrand disease (34.1%) and hemophilia A (29.3%). Neuraxial analgesia was used in 59 of 82 deliveries (72.0%). Third-trimester hemostatic profiles met predefined “adequate” thresholds in 54 of 79 evaluable deliveries (68.4%). Of the 25 deliveries below target, 13 still received neuraxial analgesia, and 10 of those received factor replacement beforehand. Antenatal recommendations from anesthesiology and hematology were documented in 47 cases, with agreement in 45 (95.7%). No epidural or spinal hematomas occurred. Minor morbidity included 1 postdural puncture headache (1.7%) and 2 cases of localized back pain (3.4%).

With multidisciplinary planning and evidence-aligned laboratory targets, neuraxial analgesia was offered safely to most pregnant individuals with bleeding disorders within our cohort. Larger multicenter studies and registry initiatives are warranted to refine factor-specific thresholds and standardize care pathways for this patient population.

•Safety evidence of neuraxial analgesia in patients with bleeding disorders remains limited.•We examined obstetric analgesia practice patterns at a tertiary care center.•Most patients with bleeding disorders safely received neuraxial analgesia.•We observed a high degree of concordance between care teams regarding neuraxial analgesia.

Safety evidence of neuraxial analgesia in patients with bleeding disorders remains limited.

We examined obstetric analgesia practice patterns at a tertiary care center.

Most patients with bleeding disorders safely received neuraxial analgesia.

We observed a high degree of concordance between care teams regarding neuraxial analgesia.