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Cesarean Delivery and Splenectomy for Severe Idiopathic Thrombocytopenic Purpura: A Case Report
Abstract Number: S 46
Abstract Type: Case Report/Case Series
Introduction: Idiopathic thrombocytopenic purpura (ITP) accounts for 3% of maternal thrombocytopenia.  We report a case with severe ITP in the third trimester who underwent cesarean delivery (CD) with intrapartum splenectomy.
Case: A 29 year-old G1P0 presented with lower extremity petechia (platelet count (PLT)=5x109/L). Bone marrow biopsy showed hypocellularity with hyperplasia of megakaryocytes. She received dexamethasone, azathioprine, repeat platelet transfusions and plasmapharesis with no sustained increase in her PLT. A thromboelastogram performed at 37 weeks gestation showed low maximum amplitude (MA) and clot stability (G) causing inability to measure clot formation time (K) (Table). After hematology and obstetric consultation, CD with concomitant splenectomy was recommended. She received a general anesthetic for elective CD with propofol and succinylcholine for induction and a remifentanil infusion at 0.5 mcg/kg/min. Prior to incision, she received methylprednisolone 40 mg to stimulate platelet function and a prophylactic dose of recombinant FVIIa 4.5 mg. The neonate had Apgar scores of 2 and 8 at 1 and 5 min. After a splenectomy was performed, she received a 4 unit platelet infusion. The total estimated blood loss (EBL) was 1L; IV fluids = 1L crystalloid. The patient was extubated and taken to the ICU in a stable fashion where she was given 6 more units of platelets, Romiplostim 250 mcg, a fusion protein analog of thrombopoietin, and methylprednisolone 60 mg. On POD1, her PLT transiently increased to 107x109/L. She required multiple rounds of steroids, azathioprine, and Romiplostim before hospital discharge. On POD6, her PLT=14x109/L, and she was discharged home. One month after CD, her PLT normalized to 271x109/L.
Discussion: The extremely low MA and G values of the preoperative TEG indicate reduced strength of clot formation which was consistent with a clinical picture of severe thrombocytopenia. A general anesthetic technique was used because neuraxial anesthesia was contraindicated with the decreased PLT. During the perioperative period, the PLT transfusion and recombinant FVIIa may have promoted clot formation and the favorable EBL. Intrapartum removal of the spleen during CD  and the use of Romiplostim post-CD can be considered for obstetric patients with severe ITP refractory to other treatment measures (corticosteroids, IVIG, splenectomy).
References: (1) Semin Hematol 2000;37: 275-89. (2) Blood 1996;88: 3-40.