Management of a Lumbar Epidural in a Patient with HELLP Syndrome and a Platelet Count of 14,000
Abstract Number: 183
Abstract Type: Case Report/Case Series
Introduction: Thrombocytopenia resulting from HELLP syndrome creates concern for the safety of neuraxial labor analgesia. The incidence of epidural hematoma after epidural labor analgesia is very low (1) but the minimal platelet count at which an epidural can be safely performed remains unknown. We present a patient with a platelet count of 14,000 who had an epidural placed without sequellae.
Case: A 23 yo G2P1 at 37 weeks gestational age presented to triage in active labor. Initial BP was 125/80 and she had no HA or visual changes. She denied any PMH except for one uncomplicated SVD with epidural. Six hours after admission she requested analgesia and a CSE was easily placed at L3-L4. BP prior to placement was 126/90. Nine hours after admission, a CBC revealed a platelet count of 14,000 (repeated and confirmed). AST was 239, ALT 244, and total bilirubin was also elevated at 1.9. PT/PTT/INR were all within normal limits. She was transfused 6 units of platelets and her count rose to 54,000. Fourteen hours after epidural placement, a male infant was born with Apgars of 9/9 and the platelet count remained 46,000. The epidural was left in place and the patient was monitored in the ICU overnight. Her epidural site remained clean and dry and she had no neurologic symptoms. Her platelet count rose over the next two days without transfusion from 38,000 to 97,000 at which time the epidural catheter was removed. She was discharged on post delivery day 3 with a platelet count of 132,000 (Figure 1).
Discussion: This case demonstrates the importance of following the platelet count in patients with HELLP syndrome, which can occur in the absence of hypertension. In our case, there was no suspicion of HELLP until abnormal lab results were reported after the epidural had been placed. While this report does not imply that neuraxial analgesia is safe with a platelet count of 14,000, it does add to a growing body of reports of neuraxial analgesia performed with platelet counts well under the conservative limit of 100,000.
1. SOAP Serious Complication Repository Project 2005-09. Presented at SOAP annual meeting 2008.