Profound, Refractory Thrombocytopenia in a Parturient
Abstract Number: F-26
Abstract Type: Case Report/Case Series
A 29-year-old G3P2 woman presented for labor and delivery in her third trimester with profound thrombocytopenia. During her second pregnancy, she was diagnosed with idiopathic macrocytic anemia and pregnancy-related thrombocytopenia (platelet nadir 120 k/mm3).
In the seventh week of her current pregnancy, platelet count (PLT) was 123 k/mm3. By 32 weeks, it was 26 k/mm3. Oral corticosteroids and intravenous immunoglobulin were given but did not slow the drop in PLT.
At 35 weeks when the patient was admitted for induction of labor, the PLT was 9 k/mm3 and skin exam revealed diffuse petechiae. Bone marrow aspirate showed no evidence of aplastic anemia or malignant/infiltrative processes. A peripheral blood smear showed normal platelet morphology, arguing against a peripheral destructive process. The case was diagnosed as a rare variant of amegakaryocytic idiopathic thrombocytopenia purpura (ITP).
To optimize platelet count and function prior to induction:
•Methylprednisolone: Suppress peripherally destructive processes.
•Packed red blood cell (pRBC) transfusion: Marginalize platelets to vessel walls.
•Rho(D) Immune Globulin infusion: Shift autoimmune destruction from platelets to RBCs.
•Surgery consultation: Evaluation should splenectomy be required.
To prepare for labor and vaginal delivery/operative delivery:
•Blood Bank: Close communication was maintained. Donor pRBCs were cross-matched and platelet availability was confirmed.
•Labor: Large-bore IV access was established. The patient was induced and allowed to labor down to minimize second stage pushing and increasing the risk of spontaneous hemorrhage.
•Delivery: Thrombocytopenia contraindicated neuraxial anesthesia. Plan for general anesthesia if caesarean section.
On the day prior to delivery, PLT nadir was 6 k/mm3. The patient underwent NSVD with normal estimated blood loss. There were no post-partum bleeding complications, and the PLT slowly began to normalize.
Pregnancy-related ITP is not uncommon (1). However, cases with profound thrombocytopenia unresponsive to conventional treatment are rare. Thrombocytopenia in the parturient increases bleeding risk and contraindicates neuraxial techniques (2). Neuraxial analgesia is seldom offered with PLT lower than 50 k/mm3, but it has been reported in a patient with counts as low as 2 k/mm3 (3).
Severe thrombocytopenia in labor requires coordination of care between anesthesia, obstetrics, hematology, transfusion medicine, and general surgery to plan for bleeding complications. Uncommon therapies such as Rho(D) immune globulin may be helpful. Splenectomy should be considered in severe cases.
1. Choi et al. Neuraxial techniques in obstetric and non-obstetric patients
with common bleeding diatheses. Anesth Analg. 2009 Aug;109(2):648-60.
2. Kam et al. Thrombocytopenia in the parturient. Anaesthesia. 2004 Mar;59(3):255-64.
3. Hew-Wing et al. Epidural anesthesia and thrombocytopenia. Anesthesia 1989;44:775–7.