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Severe, Atypical Thrombocytopenia Requiring Frequent Platelet Transfusions during Pregnancy
Abstract Number: 177
Abstract Type: Case Report/Case Series
Introduction: Thrombocytopenia complicates about 10% of pregnancies. We present a severe, atypical case of thrombocytopenia associated with anemia that required weekly platelet transfusion during pregnancy. Because she also requested a labor epidural anesthetic, a proactive, multidisciplinary approach was required to ensure her platelet counts remained at an adequate level during the peripartum period.
Case: A 24 year old G1P0 at 26 weeks gestation with a prior diagnosis of stable thrombocytopenia (100-120 K/uL) presented to our institution with severe thrombocytopenia (26 K/uL). Steroid and intravenous immunoglobulin therapies were attempted without satisfactory response. Macrocytic anemia (HCT 25.8%, MCV 108) was present with her peripheral blood smear showing tear drops and polychromasia. Abdominal ultrasound did not reveal splenomegaly and bone marrow biopsy appeared normal. A repeat platelet count after an episode of epistaxis at 25 weeks was 14 K/uL. Weekly platelet transfusions were continued throughout the third trimester. A repeat bone marrow biopsy at this time showed decreased megakaryocytes and a mildly hypocellular sample, but no evidence for a lymphoproliferative disorder. During the third trimester, she required frequent red blood cell transfusions with a goal to maintain the HCT to about 25%.
Induction was planned at term. The hematologists and blood bank pathologists were alerted and prepared to maintain several units of blood products for the peripartum period. The goal was to maintain an adequate platelet count for hemostasis during labor. Several transfusions of platelets were required during this time to maintain adequate platelet count and to ensure hemostasis into the postpartum period. She was given one unit of red blood cells. Epidural analgesia was administered without any complications or difficulties. Spontaneous vaginal delivery occurred without any maternal or fetal bleeding complications. At six weeks postpartum she reported no significant bleeding, despite a platelet count of 22 K/uL. Hematological workup is ongoing for a more definitive diagnosis. While genetic testing and repeat bone marrow biopsy are currently pending, it appears that a deficiency in bone marrow production led to the profound refractory thrombocytopenia during pregnancy.
Discussion: This case presents the successful management of a patient with refractory thrombocytopenia of unclear etiology during pregnancy. A proactive, multidisciplinary approach between obstetricians, hematologists, blood bank pathologists, anesthesiologists and nurses was required for this favorable outcome.
1. Kam PCA, et al. Thrombocytopenia in the Parturient. Anaesthesia 2004, 59:255-264
2. Cines DB. Immune Thrombocytopenia Purpura. NEJM 2002; 346: 995-1008