Lower segment cesarean section in a patient with severe thrombocytopenia and pregnancy induced hypertension
A 38-year-old female in her G4P3A0 L0 was referred from peripheral hospital at 32 weeks of gestation for safe confinement in precious pregnancy. Patient had unexplained fetal loss at 6-8th months of gestation in previous three pregnancies, on investigating for bad obstetric history during the current pregnancy she was diagnosed as a case of hypocellular bone marrow with severe thrombocytopenia with pregnancy induced hypertension (PIH) at peripheral hospital and was referred to our Tertiary Care Center for further management. On admission to hospital, patient was hemodynamically stable with blood pressure (BP) of 140/90 mmHg on Tab. methyldopa 250 mg, which was started in peripheral hospital. Laboratory analysis showed total leukocyte count 7200/μL, hemoglobin (Hb) 8.5 g/dl, hematocrit 22.6%, platelet count 6000/mm3 and blood group O negative, the blood picture showed pancytopenia and bone marrow biopsy was compatible with hypoplastic marrow.\nThere was a dilemma regarding the best possible plan in this case, considering thrombocytopenia along with concerns regarding Intrauterine growth retardation (IUGR) and fetal well-being. In the ward, the patient received 20 units of platelets, 2 units of whole blood as the patient was clinically very pale, oral prednisolone 10 mg tid, oral hematinic, but counts did not improve with repeated platelet concentrate transfusion though antiplatelet antibody and ANA were negative. Other investigations include antigen test for paroxysmal nocturnal hemoglobinopathies, factor V mutation, direct comb's test, Fanconi anemia all showed negative results with no any abnormality on Hb electrophoresis. Hematology experts had advised to transfuse single donor platelets peri-operatively.\nAs the patient deveopled leaking per vaginal and Ultra sonography (USG) Doppler showed IUGR and intermittent absent end diastolic flow, she was posted for emergency lower segment cesarean section (LSCS) before which adequate units of blood and single donor platelets were arranged. Prior to surgery, patient's fasting status was confirmed, high-risk written informed consent was taken for emergency LSCS under general anesthesia. Her hemodynamic parameters showed blood pressure of 210/100 mmHg and heart rate of 160 beats/min. Investigations revealed Hb of 9.7 g/dl and platelet count of 7000/mm3. Patient was taken in the Operation theatre and Electrocardiogram, Oxygen saturation, Non-invasive Blood Pressure monitors were attached and was administered IV Nitroglycerine of total dose 60 μg in incremental doses and IV metoprolol 1.5 mg to achieve acceptable control of blood pressure. As per hematology reference, 6 units of platelets were transfused prior to induction. Pre-medication with IV Ranitidine 50 mg and IV ondonsetron 4 mg, IV glycopyrrolate 0.2 mg, IV hydrocortisone 100 mg was administered and was pre-oxygenated with 100% oxygen. Anesthesia was induced with 300 mg of thiopentone sodium and tracheal intubation was facilitated with 100 mg of succinylcholine by rapid sequence induction-intubation technique and IV xylocard 50 mg administered to blunt the pressor response. Thereafter, anesthesia was maintained with nitrous oxide-oxygen-vecuronium. A female infant weighing 960 g was delivered with poor Apgar scores (≤4), hence shifted to neonatal intensive care unit (NICU) for further management. Midazolam 1 mg and fentanyl 100 μg was supplemented following baby delivery. Patient maintained stable hemodynamics intra-operatively and total blood loss was 1200 ml, 2 units of blood and 10 units of platelets were transfused. At the end of procedure neuromuscular blockade were reversed with neostigmine 0.25 mg and glycopyrollate 0.8 mg and trachea extubated on the operation table after confirming complete return of muscle power, tone and respiratory efforts with obeying commands.\nFollowing surgery, the patient was shifted to Post-operative Anesthesia Care Unit (PACU) for monitoring and further management. In the PACU patient received 2 units of blood, 3 units of cryoprecipitates, and 12 units of platelets as per the losses through drain. Any form of intramuscular injections was avoided. Prophylactic antibiotics were continued with IV cefuroxime 1.2 gm 12 hourly and IV metronidazole 500 mg 8 hourly. Post-operative analgesia was provided by IV paracetamol 15 mg/kg 8 hourly and post-operative persistant hypertension was controlled with continuous infusion of Nitroglycerine @ 0.5-1 μg/kg/h for next two days and then shifted to oral antihypertensive Labetalol 100 mg 12 hourly and oral prednisolone 10 mg 8 hourly was also continued. On the 2nd post-operative day investigations showed Hb of 9.8 gm, platelet count of 28000/mm3, on day three, patient was shifted to ward. She was discharged from the hospital on day 10. The patient was followed-up in the obstetric and hematology clinic and was planned for bone marrow transplant at later date.