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How Low Did We Go? A Case Report of Unexpected Thrombocytopenia
Abstract Number: F3D-3
Abstract Type: Case Report/Case Series
There is no consensus about the platelet count (PLT) threshold for performing neuraxial labor analgesia (NLA) in thrombocytopenic patients. Mitigating the risk of spinal epidural hematoma (SEH) versus that of untreated labor pain and possible difficult airway management if the need for an urgent cesarean delivery arises are the issues.(1) Current ASA/SOAP guidelines state ‘a routine platelet count is not necessary in the healthy parturient.’(2)
This is a case of NLA placed in an apparently healthy patient, who turned out to have severe thrombocytopenia at the time of NLA in the context of an unusual HELLP presentation.
A 31 year old, healthy normotensive term G1P0 in active labor requested NLA. Results of admission laboratory tests were pending. Since there were no signs or symptoms of preeclampsia and PLT was normal through pregnancy, a combined spinal epidural (CSE) was placed. Minutes after, admission PLT results returned at 25K/μl. Sodium citrate automated PLT was 14K/μl, manual count 30-40K/μl. LFTs were AST 726 U/L, ALT 678 U/L, LDH 823 U/L resulting in the diagnosis of HELLP. Coagulation studies were normal (PT 14s, aPTT 35s, INR 1.1). Vaginal delivery occurred 8h after CSE placement without major bleeding. Oxytocin 30 units/h, was started, TXA 1g and desmopressin 0.3 mcg/kg were given. PLT nadir was 18K/μl 2h post-delivery. Serial neurologic checks and PLT counts were done. The epidural catheter was left in situ until PLT increased to 99K/μl on postpartum day 4. She remained normotensive with no signs of SEH.
This rare presentation of HELLP without the usual harbinger of hypertension causes us to reevaluate, but not alter, our practice of providing NLA in parturients who appear to be healthy in whom admission laboratory results are pending. The risk of a SEH in parturients is estimated to be 1:168,000 and even with thrombocytopenia the risk is low (0.2, 3 and 11% with a PLT 70-99K/μl, 50-69K/μl, and 0-49K/μl respectively).(1, 3) While laboratory results on the day of NLA procedure are preferred, parturients are not made to wait when PLT have been normal throughout pregnancy. (2)
Since NLA is usually not performed in thrombocytopenic women, this is one of the few cases that will be reported where CSE was placed without any complication in a HELLP patient.
1. Anesthesiol 2006;105:394-9
2. Anesthesiol 2016;124:270-300
3. Anesthesiol 2017;126:1053-63