///2009 Abstract Details
2009 Abstract Details2018-05-01T17:45:11+00:00

Management of a parturient with severe rheumatoid arthritis and idiopathic thrombocytopenic purpura , complicated by anterior placenta previa .

Abstract Number: 273
Abstract Type: Case Report/Case Series

Rajashekar Reddy Gowni MD(Anaesthesia), FRCA1 ; Gauhar Sharih FRCA2; Griselda Cooper FRCA3

Introduction

Although autoimmune haematological abnormalities such as neutropenia and pure red cell aplasia have been noted in patients with rheumatoid arthritis, the association of rheumatoid arthritis with idiopathic thrombocytopenic purpura has seldom been reported (1). Idiopathic thrombocytopenic purpura may affect women of child bearing age and is the commonest autoimmune disease of pregnancy. This case discusses the anaesthetic management of a parturient with severe rheumatoid arthritis and idiopathic thrombocytopenic purpura in whom difficulties existed in providing either general or regional anaesthesia.

Case report

A 33-year-old primigravida was scheduled for caesarean section at 36 weeks gestation.Her medical history included severe rheumatoid arthritis. idiopathic thrombocytopaenic purpura, ulcerative colitis, hypertension, anaemia of chronic disease and osteoporosis. Her mobility was severely restricted and she was wheelchair bound. At the time of antenatal booking the patient had a haemoglobin of 10g% and platelet count of 100,000/L.A preoperative anaesthetic evaluation revealed poor mouth opening, a fixed neck deformity and a mallampati class 1V airway. She had a history of a failed intubation in her last general anaesthetic. She suffered with recurrent low platelets and had clinical evidence of a qualitative platelet dysfunction. The obstetric history was further complicated by anterior placenta praevia. Patient needed high dose steroids and immunoglobulins antenatally, to increase her platelet counts. A decision for a planned caesarean section was taken . Pre-operatively patient received platelet transfusion and 500 mg tranexamic acid intravenously. The anaesthetic management involved securing the airway with an awake oral fibreoptic intubation followed by induction and maintainance of general anaesthesia. The surgical procedure was uneventful allowing delivery of a live baby without any harm to the mother and an uncomplicated post-operative course.

Discussion

Deciding on the perfect anaesthetic technique was difficult in our case. The majority of anaesthetists would perform regional anaesthesia for an elective caesarean section in a parturient with a predicted difficult airway,but the safest option could be an awake fibreoptic intubation under topical anaesthesia, followed by general anaesthesia(2). Awake fibreoptic intubation is now being more widely used in obstetric practice. It is particularly valuable in cases where traditional methods of intubation have failed or abnormal anatomy is expected to make intubation difficult.

References

1. Taro Horino, Atsushi Sasoaka, Toshohiro Takao, Takafumi Taguchi, Hiroshi Maruyama. Immune thrombocytopenic purpura associated with rheumatoid arthritis: case report. Clin Rheumatol, 2005; 24; 641-644.

2. P. Trevisan. Fibreoptic awake intubation for caesarean section in a parturient with predicted difficult airway. Minerva Anestesiol 2002; 68; 775-781

SOAP 2009