Although aplastic anemia was first recognized by Ehrlich in 1888, the pathogenesis of aplastic anemia has remained elusive. The prevalence of aplastic anemia in pregnancy is rare. Aplastic anemia is a subtype of anemia characterized by pancytopenia and a hypocellular bone marrow. This condition can be due to chemicals, drugs, infections, irradiation, leukemia, and inherited disorders. The treatment involves immunosuppressive therapy with antithymocyte globulin and cyclosporine and bone narrow transplantation [1]. The relationship between pregnancy and aplastic anemia remains controversial. There is universal agreement that pregnancy complicated by aplastic anemia is a serious condition [2]. The risk to the mother is mainly in the form of hemorrhage and sepsis, while the fetus may suffer from growth restriction and even intrauterine death. Hemorrhage and sepsis are responsible for more than 90 % of maternal mortality [2]. Most of the fetal complications are due to maternal anemia. All along with these, maternal infections may lead to the development of chorioamnionitis and resultant preterm labor and birth [3]. In the literature, fetal thrombocytopenia, placentomegaly, and severe oligohydramnios have also been reported. We here present two cases of pregnancy complicated by aplastic anemia, which were seen within a span of 1 year at our hospital. This high incidence is because the hospital is a tertiary care referral unit with good hematology and blood bank support. Case A A 27-year-old primigravida, at 28 weeks of gestation, was found to have a hemoglobin level of 5.6 g/dL, during regular antenatal checkup, and was transfused 2 U of packed cells (PC). She did not have any medical or surgical problems in the past, and her antenatal investigations had been normal. Subsequently, at 30 weeks of gestation, she developed spontaneous bruising, bleeding gums, epistaxis when a complete blood count revealed a hemoglobin level of 7.3 gm/dL, white blood cell count (WBC) of 4.0 × 109/L [N13L84], and platelet count of 3.8 × 109/L and reticulocyte at 0.2 %. Bone marrow biopsy was suggestive of aplastic anemia. She was advised to take cyclosporine 5 mg/kg/day (a total dose of 300 mg), which she took for 7 days and then defaulted. When she reported to our emergency department at 32 weeks of gestation with complaints of gum bleeding and purpuric rash, her hemoglobin was 8 gm/dL, and platelets 1 × 109/L. She was transfused 2 U of platelet-rich concentrates (PRC). She developed severe gestational hypertension and was started on oral alpha methyl dopa 500 mg tds. Injection dexamethasone was given for fetal lung maturation. At 33 weeks of gestation, scan showed IUGR, and with umbilical artery, Doppler study found absent end-diastolic flow. A multidisciplinary team consisting of obstetricians, anesthesiologists, hematologists, and neonatologists planned on offering an elective cesarean section under general anesthesia for severe IUGR and fetal compromise. Eventually, at 33 weeks and 5 days of gestation, she underwent elective cesarean section delivering a healthy preterm female baby of 1,300 g with Apgar scores of 9 and 9, at 1 and 5 min, respectively. Pre-operatively, her hemoglobin was 8.4 g%, and she was transfused six PRCs, intraoperatively she was given six PRCs, 1 U of PC, and 1 U of factor-7 (2.4 mg). There were no abnormal intraoperative findings, and surgery was uneventful. She was monitored in high dependency unit, received four PRCs and one single donor platelet unit, following which her platelet count was 10 × 109/L, and hemoglobin was 10 g%. Post-operatively, she developed fever, was started on cefotaxime and gentamicin, progressing on to imipenem and teicoplanin, which was changed to amphotericin and voriconazole because of mild infusional toxicity. During the ward stay, she was supported with 52 U of PRCs and 9 U of PCs. Definitive treatments of aplastic anemia like allogenic bone marrow transplant, Antithymocyte globulin (ATGAM), and Cyclosporin were offered to the patient, but she could not avail these because of financial constraints. She was discharged on request after 49 days of hospital stay and expired after 6 days of discharge. The baby, born at 33 weeks and 5 days of gestation, weighing 1,300 g was managed uneventfully in level 2 neonatal ICU for 22 days till it attained a weight of 1,780 g. The baby was discharged back home in a good condition.
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Nov 20, 2015
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