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///2018 Abstract Details
2018 Abstract Details2019-08-02T15:57:01-05:00

Cesarean Delivery in a Patient with Severe Anemia and Thrombocytopenia of Unknown Etiology

Abstract Number: S3D-3
Abstract Type: Case Report/Case Series

Eli Zarkhin MD1 ; Amita Kulkarni MD2; Jeffrey Zahn MD3

Case Report:

A 35-year-old G1P0 was scheduled for a cesarean delivery at 36 weeks gestation for severe anemia and thrombocytopenia of unknown etiology. At 22 weeks, routine CBC showed a Hgb of 6.6 g/dl and platelet count of 11,000. She also endorsed epistaxis, bleeding gums, and increased bruising. The patient had a normal CBC with no history of bleeding prior to pregnancy. An initial bone marrow biopsy at 22 weeks demonstrated hypocellular marrow consistent with aplastic anemia, follow up biopsy at 29 weeks showed normocellular marrow with moderate megakaryocytic hypoplasia not consistent with aplastic anemia. Through her antepartum course, she required regular transfusions of packed red blood cells and platelets. While she responded appropriately to the transfusions, her anemia and thrombocytopenia persisted. She neither responded to a seven-day trial of steroids, nor to a two-day trial of intravenous immunoglobulins. PT, INR, PTT, and fibrinogen were all within normal ranges.

Admitted the night prior to cesarean, her systolic blood pressure was in the 170s mmHg; with her urine protein/creatinine ratio of 0.44, pre-eclampsia with severe features was diagnosed. Her Hgb and platelets were 7 g/dl and 45,000 and she was transfused 2 units of pRBCs and 1 pack of platelets. General anesthesia was induced using RSI with propofol 200 mg and succinylcholine 120 mg, and maintained with sevoflurane and nitrous oxide. Two packs of platelets were administered peri-incision and the surgical course was uneventful. Baby was delivered with APGAR scores of 8 and 9 while mother was hemodynamically stable, EBL was 800; no further blood products were required intraoperatively.

In PACU, Hgb was 6.6 g/dl and platelets were 150,000 at which time she received 1 unit of pRBCs. During the remaining post-operative course, she did not require any further pRBC transfusions and Hgb remained stable at 9 g/dl, but she required 2 packs of platelets to maintain her counts above 50,000. She was discharged home on PPD 5.

Four weeks postoperatively, patient presented with vaginal bleeding and hematometra. Platelets were 5,000 and Hgb 6 g/dl. She underwent a D&A, received 2 packs of platelets and 2 units of pRBCs before being discharged on HD 5.

Discussion:

This case highlights the challenges of caring for a parturient with a hematologic derangement requiring multi-disciplinary coordination including maternal fetal medicine, hematology, NICU, SICU, blood bank, and anesthesia. We chose general anesthesia because of her low platelet count and risk of hemorrhage. At the same time, it is not our common practice to perform neuraxial block if an existent coagulopathy requires transfusions as such a correction may be temporary and of uncertain quality—although each patient needs to be evaluated on an individual basis.

SOAP 2018