Thromboelastography in a Parturient with Immune Thrombocytopenic Purpura

Abstract

To the Editor: Thromboelastography (TEG) is being used in parturients to monitor coagulation [1-4]. We present a parturient with immune thrombocytopenic purpura in whom the TEG confirmed adequate platelet function before spinal analgesia. A 25-yr-old gravida 2, para 1 (previous cesarean section) presented in labor with an intrauterine demise. We were consulted because the patient desired neuraxial analgesia for labor. Medications included prednisone 40 mg daily, and there was no clinical evidence of bleeding. Hematocrit, prothrombin time (PT), and partial thromboplastin time (PTT) were normal, with a platelet count of 64 x 103 mm (-3). A celite-TEG was performed with R time 16 mm, K time 5 mm, angle 60[degree sign], maximal amplitude (MA) 68.5 mm, and percent fibrinolysis at 30 min 0.5%. Atraumatic spinal analgesia was performed with a 27-gauge Whitacre needle at L2-3 with 0.5 mL of ropivicaine (0.2%) and 25 [micro sign]g of fentanyl. Analgesia was immediate and effective, with subsequent uneventful vaginal delivery and recovery. Although we acknowledge that a single case cannot prove an important principle, it suggests the utility of the TEG in obstetric anesthesia. A platelet count of 64 x 103 mm-3 would usually preclude spinal analgesia. However, the normal angle and MA, confirming qualitative platelet function and platelet-fibrinogen interaction, allowed performance of spinal analgesia in a patient with quantitative thrombocytopenia. Although R and K times were prolonged compared with hypercoagulable parturient measures [5], the normal PT and PTT supported adequate fibrin formation. Carlos J. Campos, MD Evan G. Pivalizza, MBChB, FFASA Ezzat I. Abouleish, MD Department of Anesthesiology; University of Texas Health Science Center; Houston, TX 77030