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Anesthetic Management of a Patient with Acute Promyelocytic Anemia (APL) During Cesarean Delivery
Abstract Number: F5C-5
Abstract Type: Case Report/Case Series
Introduction: Acute promyelocytic leukemia (APL) is characterized by pancytopenia and coagulopathy, and parturients with APL are at increased risk of postpartum hemorrhage (PPH). We describe the anesthetic management of a patient with relapsed APL undergoing urgent cesarean delivery.
Case: A 35 year old G4P3 with two prior cesarean deliveries and history of APL in remission presented with relapsed APL and profound pancytopenia at 37.5 weeks EGA. She was immediately started on all-trans retinoic acid (ATRA), which can induce complete remission of APL(1); however, after spontaneous rupture of membranes on hospital day three, the decision was made to proceed with urgent cesarean delivery. Her preoperative laboratory findings were notable for hemoglobin 8.6g/dL, platelets 73K/mcL, and fibrinogen 194mg/dL. A preoperative thromboelastograph (TEG) demonstrated an R time of 5.5 min, K of 4.3 min, Angle of 45.9°, and MA of 47.1mm, all within normal limits for a (non-pregnant) individual. Following placement of an arterial line, general anesthesia was induced and patient underwent rapid sequence intubation. Maintenance anesthetic consisted of sevoflurane until delivery, followed by a mixture of sevoflurane and nitrous oxide. Although the surgeons reported somewhat increased surgical site bleeding, the operation was uncomplicated with a total estimated blood loss of 1L. The patient was extubated at the end of the case and transferred to the PACU. Postoperative labs included hemoglobin 7.6g/dL, platelets 56K/mcL, and fibrinogen 152mg/dL. One pooled unit of platelets and one unit of cryoprecipitate were transfused in the PACU, after which platelets increased to 91K/mcL and fibrinogen to 196mg/dL. Following inpatient treatment of her APL, the patient was discharged home on postpartum day 23 in stable condition.
Discussion: Patients with acute leukemia, including APL, are at increased risk for hemorrhagic complications, including postpartum hemorrhage. While data are scarce, it seems likely that these patients also have an increased risk for spinal epidural hematoma formation(2); therefore, given this patient’s favorable airway exam, we felt that general anesthesia was safer than a neuraxial technique. TEG has not been validated as a tool for predicting spinal epidural hematoma risk, but her normal preoperative values suggested that significant PPH was less likely, guiding preoperative planning for vascular access and blood product availability. Although the antifibrinolytic TXA has an emerging role in the treatment and possible prevention of PPH, it may increase thrombotic events in patients taking ATRA, and we therefore did not empirically administer TXA preoperatively(3,4).
1. Elterman KG et al. A&A Case Reports. October 15, 2014;3(8):104–106.
2. Hanke AA et al. Anaesthesia. June 2010;65(6):641-5.
3. Brown JE et al. Br J Haematol. September 2000;110(4):1010-2.
4. Pacheco et al. Gynecol . October 2017;130(4):765-769.