FRCPath Haem Part 1 MCQs-General Haem 478
A 29-year-old woman with known immune thrombocytopenia (ITP) is admitted at 39+1 weeks' gestation with painful uterine contractions and ruptured membranes. She is in established labour.
Her pregnancy has been managed jointly by obstetric, haematology and anaesthetic teams. She has received prednisolone during pregnancy with a suboptimal response.
On admission:
Hb: 108 g/L
WCC: 9.8 × 10⁹/L
Platelet count: 20 × 10⁹/L
LFT and renal function: normal
No active significant bleeding
The obstetric team is planning vaginal delivery. The patient requests an epidural for analgesia.
Which of the following is the most appropriate management plan?
A. Proceed with epidural anaesthesia and vaginal delivery
B. Give one adult therapeutic dose of platelets immediately to achieve a platelet count >70 × 10⁹/L before epidural anaesthesia
C. Perform emergency caesarean section because the platelet count is <50 × 10⁹/L
D. Give IVIG 1 g/kg, IV methylprednisolone 250 mg and IV tranexamic acid 1 g
E. Give oral prednisolone and repeat the platelet count in 24 hours
F. Platelet Transfusion and Tranexamic acid
Correct answer: D
Explanation
This patient has severe thrombocytopenia (20 × 10⁹/L) in established labour due to ITP. Her platelet count requires urgent intervention to reduce maternal bleeding risk.
The appropriate immediate treatment is:
IV immunoglobulin (IVIG) 1 g/kg
IV methylprednisolone 250 mg
IV tranexamic acid 1 g in established labour
Why neuraxial anaesthesia should be deferred
Although the precise threshold should be assessed individually by the obstetric anaesthetist, this platelet count of 20 × 10⁹/L is far below the usual threshold considered acceptable for spinal or epidural anaesthesia. A platelet count of approximately ≥70 × 10⁹/L is generally required in this clinical protocol.
Therefore, an epidural should not be inserted at a platelet count of 20 × 10⁹/L.
Why…