Coagulation testing before epidural analgesia at delivery: cost analysis

Backgound

The usefulness of coagulation tests performed before epidural analgesia for surgery or to alleviate labour pain is controversial. The aims of this study were: 1) to evaluate the prevalence of abnormal tests in a large cohort of healthy pregnant women and their association with epidural hematoma; 2) to assess the approach of the anesthesiologists to women with abnormal tests; 3) to evaluate the cost of performing coagulation tests before epidural analgesia in all healthy pregnant women.

Methods

Data regarding epidural analgesia, epidural hematoma, PT, APTT, fibrinogen and platelet count were extracted from medical charts.

Results

There was no case of epidural hematoma in 2546 pregnant women undergoing epidural analgesia. PT and APTT results were obtained in 2871 women; fibrinogen in 4063 women; platelet count in 5090 women. Three of them (0.1%) had a prolonged PT, 4 (0.14%) had a prolonged APTT, 27 (0.53%) had platelets ≤100 × 10⁹/L and 37 (0.91%) had plasma fibrinogen levels < 3 g/L. No further tests were requested by the anesthesiologists in these women. Only women with platelets < 80 × 10⁹/L were denied epidural analgesia. Based on the data from the literature on the frequencies of epidural hematoma after epidural analgesia, a total cost ranging from 4.5 to 40 million Euros to perform coagulation tests would be necessary to avoid one case of epidural hematoma.

Discussion

Unselected coagulation tests before epidural analgesia are not recommended, because epidural hematoma is extremely rare in healthy pregnant women and the cost of screening is not justified.