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Managing Thrombocytopenia in a Jehovah's Witness Parturient
Abstract Number: F-41
Abstract Type: Case Report/Case Series
Chronic isolated macrothrombocytopenia (CIMT) is a heterogenous group of disorders resulting in giant platelets with varying degrees of platelet function (1). It can account for up to 13 percent of cases of thrombocytopenia in pregnancy.
A 29 year-old G3P0 with CIMT presented for anesthesia consultation at 22 weeks gestation. At initial presentation her platelet count was 49 x 103 x µL-1. Review of her records showed a platelet count in the 30-50 x 103 x µL-1 range. She reported easy bruising but denied a history of spontaneously bleeding. The patient was offered the option of a platelet transfusion if she desired a neuraxial analgesic. She is a Jehovah’s witness and initially refused transfusion of blood products. She was offered intravenous (IV) analgesics for labor pain.
She presented at 41 weeks’ gestation for induction of labor at which time she expressed a wish to receive platelets in case of a life threatening event. A fentanyl patient-controlled analgesia (PCA) pump was started for labor analgesia: 15 microgram (mcg) bolus, 7 minute lockout, 1 hour maximum dose 180 mcg. The patient was comfortable for several hours, reporting a pain score ≤4/10. As her labor progressed the patient was more uncomfortable despite increasing her fentanyl PCA bolus dose to 20 mcg. Dexmedetomidine was added for additional pain relief starting with a bolus of 0.5 mcg/kg followed by an infusion rate at 0.2 mcg/kg/hr. Dexmedetomidine was titrated up to 0.6 mcg/kg/hr with prn boluses of 0.25 mcg/kg. Nevertheless, the patient continued to complain of severe pain despite being very sedated. The patient and her husband had a discussion regarding blood products since she desired epidural analgesia. They eventually consented to platelet transfusion. Following transfusion of 10 units of platelets, her platelet count increased from 38 to 58 x 103 x µL-1 to 72 x 103 x µL-1. An epidural was placed uneventfully and the patient was comfortable for the remainder of labor.
This report demonstrates the dilemma of having a Jehovah’s witness parturient with an uncommon form of thrombocytopenia desiring adequate analgesia during labor. A protocol of fentanyl and dexmedetomidine previously used in a parturient did not provide adequate analgesia for our patient (2). There is the ethical concern of receiving consent for transfusion of blood products from a Jehovah’s witness parturient while in pain and sedated. There are reports of parturients being able to consent to an epidural while in pain and sedated but this may not necessarily extrapolate to a Jehovah’s witness patient receiving a blood transfusion. In this particular case, relying on the patient’s autonomy throughout the process proved to a sound decision as the patient and her husband were pleased with her outcome and anesthetic care.
1. Rodriguez et al. Mayo Clinic Proc 2003
2. Palanisamy et al. IJOA 2008
3. Pattee et al. Can J Anesth 1997