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The successful interdisciplinary management of a parturient with aplastic anemia and low platelets refractory to transfusion
Abstract Number: 92
Abstract Type: Case Report/Case Series
Aplastic anemia is a rare disease with potential for high maternal and fetal morbidity and mortality. The ideal management of these patients during pregnancy is not clear and optimal care can only be ensured through ongoing interdisciplinary discussions. Our case highlights the challenges we have faced in the care of this parturient who presented to us at 39 weeks EGA with pancytopenia and platelets refractory to transfusion.
A 19 year old primipara with stable idiopathic aplastic anemia since childhood presented at full term with pancytopenia with WBC 1.8 X 109/L and platelet count of 39 x 109/L. Therapy with steroids and Romiplostim, a thrombopoietic agent and platelet transfusions failed to improve platelet counts above 50 x 109/L. Since she was term, there was a sense of urgency in developing a suitable management plan. Multidisciplinary discussions including maternal fetal medicine, blood bank, hematology and obstetric anesthesia led to formulation of the following plan:
1. Perform elective cesarean section under general anesthesia.
2. Intravenous immunoglobulin administration pre-op and into the post-op period.
3. Platelet transfusion beginning at the start of cesarean section and into the immediate post-op period.
4. Aseptic precautions because of a critically low WBC count.
The cesarean section was uneventful resulting in a healthy baby. Estimated blood loss was of 1500 cc. Post-op the patient developed acute onset pulmonary edema and was treated wtih diuretic and non invasive positive pressure support enabling her to maintain spontaneous respirations. Mother and baby were discharged home on post operative day four in stable condition.
The risk of hemorrhage due to thrombocytopenia was overcome by causing a short sustained rise in platelets during the perioperative period. Continued vigilance in the post-op period to monitor volume status was necessary. The success of this case hinged upon the coordinated care and multidisciplinary approach between obstetrics, maternal fetal medicine, hematology and anesthesia.
1.Gambling, David R, M. Joanne Douglas, Robert S. F. McKay. Obstetric Anesthesia and Uncommon Disorders. Cambridge University Press, 2008.
2.Onishi, E, Fujita, K, Yokono, S. Perioperative management of aplastic anemia in pregnancy with platelet transfusion refractoriness. Canadian Journal of Anesthesia 2007; 10: 851.