Triad of Idiopathic Thrombocytopenic Purpura, Preeclampsia, and HELLP Syndrome in a Parturient: A Rare Confrontation to the Anesthetist

Pregnancy associated coagulopathies in selected community hospitals in Southwest Nigeria

Background and Aim:

Pregnancy is characterized by multiple changes in the coagulation system which occurs at different stages of the condition, representing one of the major triggers of maternal and foetal morbidity/mortality in the world during complicated incidences. This study determined the prevalence of coagulation disorders among pregnant women in Southwest Nigeria to buttress the need for prompt and accurate routine diagnosis of these disorders.

Methods:

Four hundred and five participants (405) attending some selected tertiary health facilities in Southwestern Nigeria were randomly recruited for the study, comprising two hundred and seventy (270) pregnant subjects and one hundred and thirty-five (135) apparently healthy age- and socio-economic status-matched non-pregnant women as controls. The platelet count was assessed; prothrombin time and activated partial thromboplastin time were assessed. Immunoturbidimetric and chromogenic techniques were also used to assess the level of D-dimer and activated protein C resistance.

Results:

Platelet count, PT and INR in all three trimesters were significantly (p < 0.05) reduced when compared to the non-pregnant control subjects. However, the level of circulating D-dimer was significantly (p < 0.05) increased in all three trimesters when compared with the control group, with observable steady increase in the second and third trimesters. Also, 13% of respondents had thrombotic predisposition and 14.8% with tendencies for consumption coagulopathy while 1.1% are APCr positive individuals.

Conclusion:

The study affirms the hypercoagulable state of pregnancy coupled with mild gestational thrombocytopenia which could be pointers to onset of coagulation disorders in some participants, subjects with coagulation profiles indicative of thrombotic tendencies and possible onset of consumption coagulopathy and the presence of activated protein C resistant in the region. A review of the coagulation monitoring strategies for pregnant women from primary care to include more definite assays and its proper implementation will immensely contribute to early diagnosis along with intervention for pregnancy associated coagulopathies in resource-limited settings.

Anesthetic Management of a Parturient with Hemolysis, Elevated Liver Enzyme Levels, and Low Platelet Syndrome Complicated by Renal Insufficiency and Coagulopathy

The objective of this study is to describe the anesthetic management of a parturient with hemolysis, elevated liver enzyme levels, and low platelet (HELLP) syndrome and renal insufficiency. A 28-year-old female patient, gestational age of 35 weeks, with hypertensive crisis (blood pressure 190/110 mmHg), was admitted for an emergency cesarean section after diagnosis of HELLP syndrome and renal insufficiency. We performed total intravenous general anesthesia with rapid sequence induction. During the surgical procedure, reduced urine output and coagulopathy were detected. After the treatments of transfusion, diuresis, and anticoagulation, the surgery finished uneventfully. The patient was taken to the Intensive Care Unit without extubation and discharged on the 6^th postoperative day. This case report revealed a successful anesthetic management applied to a pregnant woman with HELLP syndrome complicated by renal insuffciency and coagulopathy. There are several case reports about HELLP syndrome, but the patient in this paper is complicated with renal insuffciency and coagulopathy which made the treatment diffcult to handle.