Anesthetic management of a parturient with aplastic anemia
Abstract Number: 230
Abstract Type: Case Report/Case Series
Introduction: Aplastic anemia is a rare occurrence in pregnancy, with serious risk for the mother and fetus. Management is described of a patient diagnosed with aplastic anemia refractory to transfusion.
Case presentation: A 29 year old G5P2113 female with history of CS presented at 23 weeks gest with frank hematuria. Platelets were 5000, and she was initially diagnosed with ITP. After no response to prednisone, intravenous immunoglobulin, or plt transfusion, a bone marrow biopsy revealed aplastic anemia. A multidisciplinary plan included serial fetal assessments, scheduled CS at 36 weeks, assuming fetal well-being, and cord blood harvesting. Treatment was cyclosporine, prednisone, aminocaproic acid mouth wash for spontaneous gum bleeding, and HLA matched plts and PRBCs, with plts remaining less than 10K. CS with BTL was done at 35-3/7 weeks for lagging fetal growth and coincided with recent increased response to plt transfusions. Preoperatively, the patient received two units of donor specific plts, hydrocortisone, metoclopramide, and clindamycin. GA included remifentanil, thiopental, succinylcholine, rocuronimum, sevoflurane, as well as small doses of esmolol, nitroglycerin and labetalol. Following delivery, cord blood was collected. A third unit of plts and unit PRBCs were given during closure. EBL was 800 ml. Cell Saver collection was insufficient to use. Postoperative was uneventful. The pt subsequently received antithymocyte globulin, prednisone, cyclosporine, and HLA matched plts and PRBCs, to keep counts above 8K and 20K. Cord blood was insufficient for stem cell transfusion and the patient had no siblings. She was discharged home at 10 weeks post CS, with weekly follow-up transfusions.
Discussion: Aplastic anemia was first described in 1888; etiology may be immunologic as it typically occurs in multiparous vs. nulliparous patients.1 Maternal mortality may be between 20 and 60%.2 There is risk of intracranial or intraoperative hemorrhage and infection,3 and fetal risk includes IUGR.1
Plans for emergent delivery included blood products, Recombinant Factor VIIa (Novo7) (90 mcg/kg), steroids, aminocaproic acid (1 gm/kg/hr) and tranexamic acid (10 mg/kg iv TID), fibrin glue, Bakri tamponade balloon, Cell Saver and rapid infusion systems. The stem cell collection kit selected accept minimal specimen (40 ml). The blood bank identified plt donors and maintained blood product supplies. Neonatologists prepared to evaluate and treat the newborn.
Early or emergent delivery could have resulted in catastrophic hemorrhage. Immunosuppression is the preferred treatment for patients who are not candidates for bone marrow transplant. Ten weeks of treatment and multidisciplinary approach resulted in controlled delivery and operative course, despite the unsuccessful harvesting of stem cells. Cell saver use which would have reduced exposure to allogenic blood products was not used.
Ref:1 AnnInternMed2002;137:164-172 2 J ObstetGynaecol2005;25:66-7