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Multidisciplinary Team Management of Vaginal Delivery with Severe Aplastic Anemia
Abstract Number: T-67
Abstract Type: Case Report/Case Series
Aplastic anemia (AA) is a rare hematologic condition characterized by pancytopenia from immune-mediated destruction of hematopoietic stem cells. Patients with AA require active supportive therapy, including aggressive broad-spectrum antibiotics for infections and frequent transfusions for severe anemia and bleeding episodes. When paired with pregnancy, these conditions pose serious challenges to the mother and fetus, especially at time of delivery. This case report discusses the successful multidisciplinary team management for a 2nd successful NSVD of a 25 year old (YO) with severe AA (sAA) complicated by immune thrombocytopenia (TCP) secondary to alloimmunization.
A 25 YO G4P1112 with sAA presented at 18.4 weeks (wks) EGA to the MFM clinic after confirmation of a 4th pregnancy. The patient (pt) was well-known to the MFM group from a previous pregnancy, where she required 8 units (U) of platelets (PLTs) with dexamethasone intrapartum and was readmitted 3 wks postpartum for symptomatic anemia at HCT 20.2% and PLT 14 x 10*9/L. During the initial prenatal visit, she had a HCT 27.1% and PLT 25 x 10*9/L. Similar to her prior pregnancy, she required intermittent pRBC transfusions antepartum for fatigue and spontaneous epistaxis with marginal responses to transfusions. Specifically at 32 wks EGA, she had no response to transfusion for a PLT 9 x 10*9/L. Hematology recommended coordinating HLA-matched PLTs (requiring 96h notice to obtain from an outside blood bank) prior to her induction at 36 wks. They noted that the pt was refractory to transfusions due to alloimmunization with a panel-reactive antibody showing 98% reactivity. Anesthesia was involved to prepare for possible general anesthesia and massive intrapartum hemorrhage.
The patient was admitted to the L&D floor at 36.2 wks EGA with a starting PLT 13 x 10*9/mL in preparation for induction. She received an IVIG transfusions every 24h, tranexemic acid every 3 hours, and one-dose of romiplostim, an analog of thrombopoietin, starting on hospital day (HD) 2. On HD3, at 36.5 wks EGA, her induction commenced. She received 1U HLA-matched PLTs with a response from PLT 9 to 24 and a second U PLT with an increase to 42 x 10*9/L. Several hours after cytotec was given the patient had a NSVD with minimal blood loss and prophylactically received 2U PLTs. Her PLT improved to 69 and 103 x 10*9/L, respectively and HCT remained stable at 30%.
Historically, patients with AA have poor prognosis in the setting of pregnancy. However, one retrospective study reported successful pregnancy management with immunosuppressants or allogeneic bone marrow transplants for 36 periparturients. On rare occasions, these therapies are ineffective, AA relapses, or treatment options are not easily accessible. This case discusses sAA complicated by alloimmunization and successful multidisciplinary team management during the intrapartum period.