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Cesarean Delivery During Maternal Sepsis After Platelet Transfusion: Timing is Everything
Abstract Number: T-17
Abstract Type: Case Report/Case Series
Platelets (PLTs) are transfused in the US at a rate of 7 million units each year (1), and account for the highest incidence of transfusion-related bacteremia (1 in 100,000 units, compared to 1 in 5,000,000 for packed red blood cells)(2).
A 29 y.o.G2P1 presented at 38 weeks’ gestation with a history of chronic thrombocytopenia (PLT count 12-20K) and anemia from primary bone marrow suppression. A multidisciplinary delivery plan was made for PLT transfusion to a goal of 70 x 103 x uL-1, induction of labor, and epidural analgesia. She received a single-donor PLT transfusion just prior to her scheduled induction; while being transfused complained of shortness of breath, chest tightness and back pain. The transfusion was discontinued and the PLT bag sent for analysis. The patient became somnolent, tachycardic and febrile. Blood cultures were drawn and broad-spectrum antibiotics were started. Analysis of the transfusate revealed that it was day 5 of storage and contained gram-positive cocci in chains. Intravenous cefteroline was chosen as an agent that may cross the placenta and provide coverage of presumed, and later confirmed, staphylococcus bacteremia. She required admission to MICU for hemodynamic monitoring. The FH was category I with the exception of fetal tachycardia during maternal fever. Fluid resuscitation for sepsis had caused increased airway edema, with a Mallampati score from 2 to 4 and restricted mouth opening. Her PLTs and hematocrit were 25K and 20%, respectively. A decision was made to postpone cesarean delivery (CD) for time to mitigate airway edema. The patient developed severe preeclampsia after 36 hrs and underwent CD under general anesthesia. Her intubation was performed with a video laryngoscope, grade 1 view. She received PLT and blood transfusions prior to incision. After an uncomplicated CD, the patient was transported to the surgical ICU, and extubated without difficulty several hours later. Clinical status improved, suggesting that the placenta and fetus may have been a nidus for bacteria. However, placental pathology did not reveal infected tissue and the neonatal blood cultures were negative.
Transfusion-associated sepsis is a serious complication most commonly attributed to PLTs (1). The risk of sepsis can be lowered through use of single-donor PLTs and shorter storage intervals (3). The altered immune state in pregnancy may render greater risk for developing sepsis after contaminated PLT transfusion. The onset and etiology of sepsis can guide timing of delivery: while worsening chorioamnionitis triggers immediate CD, cases of abrupt bacterial load can be managed differently. Allowing time for this patient to stabilize with antibiotic coverage and diuresis facilitated a favorable outcome after CD under general anesthesia.
1. Breecher et al. Clin Micro Rev 2005
2. Kuehnert et al. Transfusion 2001
3. Morrow et al. JAMA 1991