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Management of a Parturient with Aplastic Anemia and Cerebral Arteriovenous Malformation
Abstract Number: SU-98
Abstract Type: Case Report/Case Series
INTRODUCTION: Aplastic anemia is a rare complication of pregnancy and places the parturient at increased risk for bleeding at delivery. Cerebral arteriovenous malformation (AVM) places patients at risk for cerebral hemorrhage, however a further increase in risk in the setting of pregnancy is unclear. This case describes a patient diagnosed with aplastic anemia and cerebral AVM during pregnancy, and delivered via scheduled cesarean section (C/S) with a subarachnoid block.
CASE: A 26 year old G1P0 presented at 26w6d gestational age (GA) as a transfer from outside hospital with newly diagnosed aplastic anemia. She was initially evaluated at 19 weeks GA due to new onset ecchymosis and thrombocytopenia. A bone marrow biopsy revealed hypocellular marrow (<10%) without evidence of malignancy. She was transferred due to exhaustive use of blood products at the outside hospital.
Upon transfer, she continued to received serial packed red blood cell and platelet transfusions with goal hemoglobin >8 g/dL and platelets >20 10*9/L. At 30 weeks GA she developed acute, transient left sided vision changes. Ophthalmologic exam was notable for papilledema. A brain MRI revealed a R-sided occipital-parietal AVM. Per Neurosurgery, further evaluation with angiogram was postponed until after delivery. EEG was reassuring for the absence of seizure activity.
A multidisciplinary team meeting, including representation from Anesthesiology, Maternal Fetal Medicine, Hematology, Transfusion Medicine and Neurosurgery, took place to plan for delivery. The patient was delivered at 34 1/7 weeks via scheduled cesarean section. She was transfused the morning of surgery to a hemoglobin of 10.7 (goal > 10) and platelets 118 (goal > 80). A subarachnoid block was placed using hyperbaric bupivacaine 0.75% 13.5mg, morphine 0.1mg and fentanyl 15mcg. She received 1g of tranexamic acid prior to incision. The patient underwent cesarean section and bilateral tubal ligation without complication. Estimated blood loss was 800ml. Platelet count was maintained at >/= 60 for 24 hours postoperatively.
1. Rathore, Swati et al. “Aplastic Anemia in Pregnancy.” Journal of Obstetrics and Gynaecology of India 64.Suppl 1 (2014): 26–28. PMC. Web. 6 Feb. 2016.
2. Liu, Xing-ju et al. “Risk of Cerebral Arteriovenous Malformation Rupture during Pregnancy and Puerperium.” Neurology 82.20 (2014): 1798–1803. PMC. Web. 6 Feb. 2016.