Anesthetic Management of a Pregnant with Thrombocytopenia

Abstract

Providing safe and effective way to relief labor pain, which can be the most severe pain that a woman experiences during her lifetime (Melzack, 1984), is a major role of an anesthetist in obstetrics. Moreover, perioperative management of ill obstetric patients is an important part as well. One of the commonly seen conditions that an anesthetist should be well prepared for is thrombocytopenia in pregnancy. In the vast majority of women during normal pregnancies platelet counts are within the normal range of 150,000 to 450,000/µl, but they may be slightly lower than in healthy, non pregnant women (Paidas et al., 1995). 8% of pregnant women have a platelet count less than 150,000/µl and 0.9% of pregnant women have a platelet count less than 100,000/µl. (Gaiser, 2014)

The most common cause of low platelet counts in pregnancy is gestational thrombocytopenia; representing 70% of the cases. In the second place comes hypertensive disorders of pregnancy; representing 21%, including preeclampsia, eclampsia and HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets) syndrome. Finally idiopathic thrombocytopenia (ITP) is the cause of thrombocytopenia in 3% these cases. (Vera, 2012; Gaiser, 2014)

Asymptomatic thrombocytopenia is observed near term in about 5% of normal pregnancies, and thrombocytopenia develops in about 15% of women with preeclampsia (Burrows and Kelton, 1993), which itself occurs in about 7-10% of pregnancies (Vera, 2012). HELLP syndrome develops in approximately 0.1 to 0.8% of pregnancies overall and in 10 to 20% of women with severe preeclampsia/eclampsia (Sibai, 2014). ITP occurs in approximately 1 in 1000 to 1 in 10,000 pregnant women. (George and Knudtson, 2014) The clinical picture can range from asymptomatic or mild forms as in gestational thrombocytopenia (Burrows and Kelton, 1993) to severe forms; platelet counts less than 50,000/µl is seen in less than 5% of preeclamptic women. Besides, the frequency and severity of thrombocytopenia increase with the severity of preeclampsia, and are further increased in patients with the HELLP syndrome or those with full blown eclampsia with disseminated intravascular coagulopathy (Sibai et al., 1995)