Analgesia de parto em paciente portadora de deficiência de proteína S: relato de caso
Labor analgesia in protein S deficient patient: case report
Renato Mestriner Stocche; Luis Vicente Garcia; Marlene Paulino dos Reis; Jyrson Guilherme Klamt
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Abstract
BACKGROUND AND OBJECTIVES: Deficiency in protein S, which is a glycoprotein with anticoagulant activity, increases the risk for thromboembolic events. This report aimed at addressing anesthetic management of protein S deficient obstetric patient.
CASE REPORT: Protein S deficient patient, at 25 weeks gestation, presented the following lab results: INR = 0.9, TTPA = 32 s (control 25.6), protein S = 35% (normal = 70% to 130%). In the last three gestation quarters she has received up to 12,000 IU heparin every 8 hours. With 38 weeks, she was admitted in labor. After 8 uninterrupted heparin hours, already with TTPA of 25.8 s (control 27.8 s) epidural anesthesia was induced with 6 ml of 0.2% bupivacaine and fentanyl (20 µg), followed by continuous infusion. Infusion time was 5 hours with total 40 mg bupivacaine dose. There have been no intercurrences and 1 hour after catheter removal, subcutaneous 10,000 IU heparin were restarted at 12-hour intervals. Patient and neonate evolved well and were discharged 3 days later.
CONCLUSIONS: Protein S deficient pregnant patients should receive anticoagulants to maintain TTPA twice the control value. Heparin, for not crossing placental barrier, is the anticoagulant of choice in obstetrics. Blockade may be induced respecting a minimum period of 4 to 6 hours between last heparin dose and lumbar puncture, provided lab tests are within normal ranges. In these cases, however, epidural analgesia may help in preventing thromboembolic events.
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Referências
Yamazaki T. Molecular biological analysis of hereditary thrombophilia-genetic characterization of protein S deficiency. Rinsho Ketsueki. 1995;36:299-302.
Dahlbäck B, Wiedmer T, Sims PJ. Binding of anticoagulant vitamin K-dependent protein S to platelet-derived microparticles. Biochemistry. 1992;31:12769-12777.
Faioni EM, Valsecchi C, Palla A. Free protein S deficiency is a risk factor for venous thrombosis. Thromb Haemost. 1997;78:1343-1346.
Formstone CJ, Wacey AI, Berg LP. Detection and characterization of seven novel protein S (PROS) gene lesions: evaluation of reverse transcript-polymerase chain reaction as a mutation screening strategy. Blood. 1995;86:2632-2641.
Lefkowitz JB, Clarke SH, Barbour LA. Comparison of protein S functional and antigenic assays in normal pregnancy. Am J Obstet Gynecol. 1996;175:657-660.
Deitcher SR, Erban JK, Limentani AS. Acquired free protein S deficiency associated with multiple myeloma: a case report. Am J Hematol. 1996;51:319-323.
Sugerman RW, Church JA, Goldsmith JC. Acquired protein S deficiency in children infected with human immunodeficiency virus. Pediatr Infect Dis J. 1996;15:106-111.
Levin M, Eley BS, Louis J. Postinfectious purpura fulminans caused by an autoantibody directed against protein S. J Pediatr. 1995;127:355-363.
Ginsberg JS, Demers C, Brill Edwards P. Acquired free protein S deficiency is associated with antiphospholipid antibodies and increased thrombin generation in patients with systemic lupus erythematosus. Am J Med. 1995;98:379-383.
Hanevold CD, Lazarchick J, Constantin MA. Acquired free protein S deficiency in children with steroid resistant nephrosis. Ann Clin Lab Sci. 1996;26:279-282.
Simioni P, Sanson BJ, Prandoni P. Incidence of venous thromboembolism in families with inherited thrombophilia. Thromb Haemost. 1999;81:198-202.
Ganesan V, McShane MA, Liesner R. Inherited prothrombotic states and ischaemic stroke in childhood. J Neurol Neurosurg Psychiatry. 1998;65:508-511.
Siqueira Neto JI, Santos AC, Fábio SR. Cerebral infarctions in young patients related to deficiency of natural anticoagulants. Protein C and protein S. Arq Neuropsiquiatr. 1996;54:590-594.
Arias F, Romero R, Joist H. Thrombophilia: a mechanism of disease in women with adverse pregnancy outcome and thrombotic lesions in the placenta. J Matern Fetal Med. 1998;7:277-286.
Bonnar J, Green R, Norris L. Inherited thrombophilia and pregnancy: the obstetric perspective. Semin Thromb Hemost. 1998;24(^s1):49-53.
Tripodi A, Bertina RM, Conard J. Multicenter evaluation of three commercial methods for measuring protein S antigen. Thromb Haemost. 1992;68:149-154.
Rosenfeld BA, Beattie C, Christopherson R. The perioperative ischemia randomized anesthesia trial study group: the effects of different anesthetic regimens on fibrinolysis and development of postoperative arterial thrombosis. Anesthesiology. 1993;79:435-443.
Breslow MJ, Parker SD, Frank SM. Determinants of catecholamine and cortisol response to lower-extremity revascularization. Anesthesiology. 1993;79:1202-1209.
Rosenfeld BA, Faraday N, Campbell D. Hemostatic effects of stress hormone infusion. Anesthesiology. 1994;81:1116-1126.
Hoffmann R. The thrombo-embolic risk in surgery. Hepatogastroenterology. 1991;38:272-278.
Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia: their role in postoperative outcome. Anesthesiology. 1995;82:1474-1505.
Modig J, Malberg P, Karlstrom G. Effect of peridural versus general anaesthesia on calf blood flow. Acta Anaesthesiol Scand. 1980;24:305-309.
Donadoni R, Baele G, Devulder J. Coagulation and fibrinolytic parameters in patients undergoing total hip replacement: Influence of anaesthesia technique. Acta Anaesthesiol Scand. 1989;33:588-589.
Bateman A, Singh A, Kral T. The immune-hypothalamic-pituitary-adrenal axis. Endocrine Rev. 1989;10:92-112.
Rao TLK, El-Etr AA. Anticoagulation following placement of epidural and subarachnoid catheters: an evaluation of neurologic sequelae. Anesthesiology. 1981;55:293-296.
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