Labor Analgesia in a Patient With Paroxysmal Nocturnal Hemoglobinuria With Thrombocytopenia:

The management of Cesarean delivery in a parturient with paroxysmal nocturnal hemoglobinuria complicated by severe preeclampsia

PURPOSE

To describe the anesthetic and peripartum management of a parturient with paroxysmal nocturnal hemoglobinuria complicated by severe preeclampsia, review the pathophysiology of this condition, rationale for thromboembolic prophylaxis, and its implications on the choice of labour analgesia and anesthesia.

CLINICAL FEATURES

A 35-yr-old primigravida was diagnosed with paroxysmal nocturnal hemoglobinuria at 18 weeks gestation following new onset pancytopenia. Venous thromboembolic prophylaxis with low molecular weight heparin (LMWH) was started, and continued despite a persistent thrombocytopenia. At 34 weeks, labour was induced after she developed signs of severe preeclampsia, and intravenous magnesium sulfate therapy was commenced. The use of a twice daily dosing regime of LMWH, along with severe thrombocytopenia contraindicated neuraxial anesthesia. As a result, labour analgesia was provided with an intravenous patient-controlled analgesia system with fentanyl. The patient subsequently had an uneventful Cesarean delivery under general anesthesia. Anticoagulation with LMWH was restarted postoperatively, and continued for six weeks postpartum. She was discharged home on day 20 postpartum, on oral prednisolone under the care of the hematologists.

CONCLUSION

Paroxysmal nocturnal hemoglobinuria is associated with an increased risk of venous thromboembolism, and so anticoagulation therapy assumes primary importance. The use of LMWH for prophylaxis in combination with thrombocytopenia may contraindicate neuraxial anesthesia. General anesthesia should be aimed at preventing or exacerbating complement mediated intravascular hemolysis.

Clinical Management of Paroxysmal Nocturnal Hemoglobinuria in Pregnancy: A Case Report and Updated Review

Because women with paroxysmal nocturnal hemoglobinuria (PNH) are especially vulnerable to thromboembolic phenomena, pregnancy is a time of increased risk for both mother and fetus. However, pregnancies in affected women are rare; only case reports and small studies have been reported so far. We present the case of a 20-year-old woman with PNH who, while undergoing medical tests in preparation for a bone marrow transplant, was discovered to be pregnant. We also review the obstetric literature on pregnancy complicated by PNH, which indicates that both maternal and fetal mortality is exceptionally high (11.6% and 7.2%) with the major cause of maternal mortality being thromboembolism. Major maternal complications are more frequent postpartum (30.2%) than antepartum or intrapartum (16.3%).

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to recall that paroxysmal nocturnal hemoglobinuria (PNH) during pregnancy increases adverse events for both the mother and the fetus, state that maternal and fetal mortality are both high, and explain that the major complications occur in the postpartum period.

Management of a parturient with paroxysmal nocturnal haemoglobinuria

We present the case of a 30-year-old parturient diagnosed in the first trimester of her first pregnancy as having paroxysmal nocturnal haemoglobinuria. Pancytopenia necessitated regular transfusion of blood products. The risks of infection, haemorrhage and thrombosis, in the presence of severe thrombocytopenia, mild neutropenia and prophylactic anticoagulation, posed management challenges. We discuss the pathophysiology of paroxysmal nocturnal haemoglobinuria and the impact of pregnancy on the disorder, particularly on maternal morbidities such as thrombosis. The issues relevant to antenatal and peripartum obstetric, haematological and anaesthetic care for vaginal delivery are considered. Severe thrombocytopenia proved a contraindication to regional techniques and she required general anaesthesia for evacuation of a retained placenta. The post-partum period was complicated by fever and a requirement for blood products. Management of these problems, of prophylactic anticoagulation and subsequent therapy, are discussed.

General Anesthesia for Cesarean Delivery in a Patient with Paroxysmal Nocturnal Hemoglobinuria and Thrombocytopenia

Pregnancy in patients with paroxysmal nocturnal hemoglobinuria (PNH) increases the risk of complement activation, hemolysis, and thrombosis. We describe the anesthetic management of a patient with PNH who underwent general anesthesia for cesarean delivery. Steroids, heparin, and blood products were administered early to minimize the likelihood of a hematologic emergency.

IMPLICATIONS

Pregnancy in patients with paroxysmal nocturnal hemoglobinuria increases the risk of hemolysis, thrombosis, anemia, and thrombocytopenia. We describe the anesthetic management of a patient with paroxysmal nocturnal hemoglobinuria and thrombocytopenia who underwent general anesthesia for cesarean delivery.