ITP and pregnancy

[huktonfonix]

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Heres another one for thought. healthy 30ish parturient. ITP s/p splenectomy 5 years ago. Currently on no meds, but receiving IVIG prn (approx 1-2 x/month). PLT count is currently 120 and there are no clinical signs of bleeding. Do you do an epidural or not?

 

[rsgillmd]

Heres another one for thought. healthy 30ish parturient. ITP s/p splenectomy 5 years ago. Currently on no meds, but receiving IVIG prn (approx 1-2 x/month). PLT count is currently 120 and there are no clinical signs of bleeding. Do you do an epidural or not?

I can't cite a source for you at this time (I'll try to look), but I asked a similar question to an attending when I was a resident. The take home points I got were:

If the mother is asymptomatic (like this patient) and PLT count is >60,000, regional should be fine. Platelet function is probably not impaired.

If the patient is symptomatic, I would probably avoid neuraxial anesthesia and treat her medically (IV PCA for pain management, steroids, IVIG). If this patient has a difficult airway, I would make it very clear to the obstetricians that they should not call a "stat" section but rather do one earlier (when doubts about vaginal delivery begin to appear) in a controlled manner (so I have time for awake fiberoptic if I feel I want to go that route).

 

[isoman2000]

No signs of bleeding? None? does she bruise easily blood in the sink after she brushes her teeth, bleed like stink when they started her IV? if no then I would give epidural anesthesia, or SAB.

 

[huktonfonix]

yup, same train of thought, although I probably wouldnt have done it if the PLT count was below 100. On an otherwise healthy patient, perhaps, but not with the ITP comorbidity. The question is, is platelet function compromised aside from the absolute number in ITP? The possibility is there and this is the "textbook answer". However, I tend to agree that in the absence of clinical signs/symptoms it should be safe.

 

[rsgillmd]

No signs of bleeding? None? does she bruise easily blood in the sink after she brushes her teeth, bleed like stink when they started her IV? if no then I would give epidural anesthesia, or SAB.

Isoman, I hear what you are saying and will not disagree with it. However, not bleeding like stink when the IV is started doesn't necessarily mean anything, as I learned recently. When I have a little more time, I'll bring the case up in the private forum. Trust me, I lucked out.

 

[MTGas2B]

The only thing we might do different at my institution is send a TEG. There is zero evidence to support that decision, even the attendings push for TEGs will admit that. Its nice in a situation where you're on fence and you want something that makes you a little for comfortable with coagulation, the TEG at least makes you feel better.

Previously, with our old TEG machines the OB anesthesiologist and the lab folks had developed normals in pregnant women, and we would use those. However the lab bought a new TEG machine, and they haven't generated a new set with the new machine. We still get TEGs though.

The scenario we like to use TEGs in is pre-eclampsia. The women who have worsening pre-e, falling, but low normal platlets and now the OBs want to section. We'll start sending TEGs with their pre-e labs if it looks like a c-section is on the horizon. Our ob residents are pretty tuned into this, and they'll make sure they ask us if we want TEGs.

 

[pgg]

When I have a little more time, I'll bring the case up in the private forum. Trust me, I lucked out.

Can we keep the clinical threads in the main forum? I know all the cool kids hang out in the private forum, but there are surely students, non anesthesiology residents, and guys like me who just haven't bothered to join who might benefit.

Just because you almost bumped someone off is no reason to not post it out here in the bright lights of the public forum. 🙂 It's a dangerous job and I'm sure nearly everyone here has made potentially fatal errors or missteps.

 

[rsgillmd]

Can we keep the clinical threads in the main forum? I know all the cool kids hang out in the private forum, but there are surely students, non anesthesiology residents, and guys like me who just haven't bothered to join who might benefit.

Just because you almost bumped someone off is no reason to not post it out here in the bright lights of the public forum. 🙂 It's a dangerous job and I'm sure nearly everyone here has made potentially fatal errors or missteps.

pgg, thanks for the laugh. No I didn't nearly bump her off. Not that bad. Basically I did a single shot clean spinal for an emergency C/S. Labs came back later showing INR was 9 when I did the spinal. When the labs came back she began to show symptoms of DIC. Until then everything seemed OK (atony resolved). Had to put her to sleep anyway (turned out not to be a difficult airway although she could have been on exam) so they could finish exploring and close. DIC resolved in a couple of hours. When she was extubated, luckily neurologic exam didn't show any deficits. I was concerned about a spinal hematoma. She never developed one.

I'll post full details later when I have the time to sit down and write it out in a coherent manner. Right now I'm browsing the web in short bursts between other things.