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CC BY 4.0 · Rev Bras Ginecol Obstet 2018; 40(12): 803-807
DOI: 10.1055/s-0038-1675186
Case Report
Thieme Revinter Publicações Ltda Rio de Janeiro, Brazil

Refractory Severe Thrombocytopenia during Pregnancy: How to Manage

Trombocitopenia grave refratária na gravidez: como abordar
Joana Gomes de Amorim
1   Department of Anaesthesiology, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
,
Manuel Rocha Abecasis
1   Department of Anaesthesiology, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
,
Filipa Maria Nogueira Lança Rodrigues
1   Department of Anaesthesiology, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
› Author Affiliations
Further Information

Publication History

11 June 2018

23 August 2018

Publication Date:
07 December 2018 (online)

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Abstract

Thrombocytopenia is the most common hemostatic change in pregnancy, but severe thrombocytopenia is rare. One of the causes, immune thrombocytopenic purpura (ITP), is characterized by increased platelet destruction by immunoglobulin G (IgG) antibodies, presenting a high risk of hemorrhage for the patient, but also for the fetus, since antibodies may cross the placenta. We present the case of a 23-year-old pregnant woman with a history of Langerhans cell histiocytosis of the mandible submitted to surgery and chemotherapy when she was 10 years old, with diagnosis of ITP since then. At 28 weeks of gestation, she presented with petechiae, epistaxis, and gingival bleeding, with a platelet count of 3 × 109/L and positive IgG antiplatelet antibodies test. At a multidisciplinary discussion, it was decided to delay a cesarean section, due to the absence of fetal distress and to the high risk of morbidity for the patient. Many therapies were attempted without success. The IgG produced a slight and transient increase in the platelet count. On the 36th week of gestation, an elective cesarean section was performed. The perioperative period transfusions were guided by rotational thromboelastometry (ROTEM) monitoring. The procedure was performed under general anesthesia and videolaryngoscopy-assisted intubation. The patient was hemodynamically stable, without significant bleeding, and was transferred to the intensive care unit. The platelet count eventually decreased and a splenectomy was performed. Regional anesthesia may be contraindicated, and general anesthesia is associated with an increased risk of airway hemorrhage due to traumatic injury during the tracheal intubation and of hemorrhage associated with the surgical procedure. A multidisciplinary approach is essential in high-risk cases.

Resumo

A trombocitopenia é a alteração da hemostase mais comum na gravidez. Contudo, a trombocitopenia grave é rara. Uma das suas causas, a púrpura trombocitopênica imunológica (PTI), é caracterizada pelo aumento da destruição plaquetária por anticorpos de imunoglobulina G (IgG), apresentando alto risco de hemorragia para a paciente e também para o feto, uma vez que os anticorpos podem atravessar a placenta. Apresentamos o caso de uma grávida de 23 anos com histórico de histiocitose de células de Langerhans da mandíbula submetida a cirurgia e quimioterapia aos 10 anos de idade, com diagnóstico de PTI desde então. Na 28a semana de gestação, a paciente apresentou um quadro de petéquias, epistaxe e hemorragia gengival, com contagem plaquetária de 3 × 109/L e teste de anticorpos antiplaquetários IgG positivo. Em uma discussão multidisciplinar, decidiu-se adiar a cesariana devido à ausência de sofrimento fetal e ao alto risco de morbidade para a paciente. Muitas terapêuticas foram tentadas sem sucesso. A IgG produziu apenas um ligeiro e transitório aumento na contagem plaquetária. Na 36ª semana de gestação, foi realizada uma cesariana eletiva. As transfusões no período perioperatório foram guiadas por tromboelastometria rotacional (ROTEM). O procedimento foi realizado sob anestesia geral e intubação assistida por videolaringoscopia. A paciente manteve-se hemodinamicamente estável, sem hemorragia significativa. Ela foi transferida para a unidade de terapia intensiva. A contagem plaquetária continuou a diminuir, e a paciente foi submetida a uma esplenectomia. Nestes casos, a anestesia regional pode ser contraindicada, e a anestesia geral está associada a um risco aumentado de hemorragia das via aéreas devido a lesão traumática durante a intubação traqueal e de hemorragia associada ao procedimento cirúrgico. Uma abordagem multidisciplinar é essencial em casos de alto risco.

Keywords

pregnant woman - thrombocytopenia - idiopathic thrombocytopenic purpura - thromboelastometry - hemorrhage

Palavras-chave

grávida - trombocitopenia - púrpura trombocitopénica idiopática - tromboelastometria - hemorragia
 

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