///2010 Abstract Details
2010 Abstract Details2018-05-01T17:52:49+00:00

Anesthetic Management for the Parturient presenting with Hematemesis and Thrombocytopenia

Abstract Number: 246
Abstract Type: Case Report/Case Series

Clint S. Wong BSc. MD.1 ; Nevin Kilpatrick MBCHB, CCFP, FRCPC2; Roanne Preston MD, FRCPC3

Introduction: Thrombotic thrombocytopenic purpura (TTP) is a rare life-threatening condition associated with significant mortality (1). Presentation is usually with thrombocytopenia, schistocytosis, anemia and markedly elevated lactate dehydrogenase. We describe the multidisciplinary management of a 44 year-old female with twin gestation who presented with hematemesis, thrombocytopenia, acute renal and liver failure.

Case: A 44 year-old female with 27+6 twins presented to obstetric triage with a 8-hour history of acute epigastric pain and large coffee-ground emesis. Pregnancy history revealed hyperemesis gravidarum; past medical history unremarkable. Initial vital signs: BP 116/70, HR 120, SpO2 100%, GCS of 15, fetal heart rates unobtainable. Airway exam normal. Resuscitation with 1L of crystalloid, 1L of colloid was started along with pantoprazole therapy while internal medicine evaluated the patient. Lab results: Hb 11.0 g/L, HCT 0.317, platelets 27 x 109/L, creatinine 316 mol/L, AST 729 U/L, ALT 520 U/L. The differential diagnosis was: HELLP syndrome, acute fatty liver of pregnancy, idiopathic hemolytic anemia, disseminated intravascular coagulation, with upper gastrointestinal bleed. Intrauterine fetal death of one twin was confirmed, and ten units of platelets transfused prior to stat Cesarean delivery of the surviving twin for abnormal FH trace. General anesthesia was induced with thiopental, fentanyl, and succinylcholine and maintained with desflurane/O2/N20. Intraoperatively, the patient was hemodynamically stable but required 1U PRBC for post-induction hemoglobin of 5.4 g/L. Hematology called to report high percentage schistocytes on the blood film, and with LDH of 4972 U/L, felt TTP was likely. She was transferred to ICU and after six days of plasma exchange therapy, platelets were 180 x 109/L. ICU stay was 12 days and she was discharged with the diagnoses of TTP and Mallory-Weiss tear.

Discussion: In the parturient, presentation of acute illness with thrombocytopenia after 20 weeks gestation is usually secondary to preeclampsia/HELLP or DIC secondary to abruption or intrauterine fetal demise.(2,3) Although TTP is rare, pregnant women comprise 10-25% of cases.(3) Organ ischemia from microthrombotic vascular occlusion threatens lives of both fetus and mother; delivery does not alter disease course.(3) Plasma exchange therapy has increased survival to 80%.(1) Hematemesis in the parturient is rarely seen, usually from peptic ulcer disease or Mallory-Weiss tear from vomiting. Regional anesthesia following platelet transfusion was not considered for cesarean delivery given other maternal issues.

Ref:

1. George JN. Thrombotic thrombocytopenic purpura. NEJM 2006;354:1927-35.

2. Sibai BM. Imitators of severe preeclampsia. Semin Perinatol 2009; 33(3):196-205.

3. Proia A et al. Thrombotic thrombocytopenic purpura and pregnancy: a case report and a review of the literature. Ann Hematol 2002;81:210-14.

SOAP 2010