LETTER TO THE EDITOR

Artifactual severe thrombocytopenia in a pregnant patient

Michael A. Frolich • Alan Tita • Kevin Harris

Received: 17 August 2011 / Accepted: 7 June 2012

� Springer-Verlag 2012

Dear Editor,

We recently treated a 23-year-old patient who presented to

the labor and delivery unit with an extremely low platelet

count. A thorough hematological work up revealed that the

degree of thrombocytopenia was overestimated by the

automated platelet count and that functionally this patient’s

coagulation was not affected. The patient labored for sev-

eral hours but eventually required a cesarean section for

arrested active phase of labor. The differential diagnosis of

thrombocytopenia of pregnancy includes gestational

thrombocytopenia, preeclampsia, idiopathic thrombocyto-

penia purpura (ITP) and pseudo-thrombocytopenia, a lab-

oratory artifact. This case highlights the situation where

pseudo-thrombocytopenia occurred in a patient with ITP

[1, 2].

The patient, a 23-year-old 41 weeks primigravida,

height 157.5 cm, weight 99.3 kg, was transferred to the

university hospital by her primary obstetrician because of a

history of low platelets as a child, presumed to be due to

ITP. The patient did not have any symptoms of pre-

eclampsia or clinical bleeding. The preexisting

thrombocytopenia precluded gestational thrombocytope-

nia, the most common cause in pregnancy.

On admission, her platelet count was 12.7 9 109 L-1

but she did not show any evidence of petechiae or bruising,

her INR was 0.94, prothrombin time 12.7 s and partial

thromboplastin time was 24 s. To verify the extremely low

platelet count, we examined the peripheral blood smear

that confirmed that she had marked thrombocytopenia

without platelet clumps. The few normal sized platelets

appeared healthy with normal granulation. In addition, her

smear showed frequent giant platelets (Fig. 1), which are

not properly counted by the automated cell counter but are

highly active in hemostasis [1, 2]. As next step in our work

up we ordered a thromboelastogram (TEG) to examine the

patient’s efficiency in clot formation as reported previously

[3, 4]. All TEG parameters were within normal limits

(R-time 7.1 min, alpha angle 67.3�, maximum amplitude

62.3 mm).

Based on the normal TEG and coagulation tests (PTT,

INR) and the expert opinion of the consulting hematologist,

we decided to offer epidural analgesia, also recognizing

there is not a universally acceptable platelet count that is

considered safe for neuraxial blockade [5]. After a thor-

ough risk benefit discussion with the patient, she chose to

proceed with epidural analgesia. The patient’s labor did not

progress beyond 4 cm cervical dilation, necessitating a

low-transverse cesarean section, which was performed

under epidural anesthesia with an uncomplicated postop-

erative course. Her platelet count remained stable around

30–50 9 109 L-1 requiring no therapy such as steroid

therapy or Rho immunoglobulins (RhIG).

Typically, patients with severe thrombocytopenia

undergoing cesarean may be given perioperative platelet

transfusion (typically for levels less than) and a midline

skin incision as opposed to a Pfannenstiel incision may be

M. A. Frolich (&)

Department of Anesthesiology, Center for the Development

of Functional Imaging (CDFI), University of Alabama at

Birmingham (UAB), Jefferson Tower 868C, 619 South

19th Street, Birmingham, AL 35080, USA

e-mail: froelich@uab.edu

A. Tita

Department of Obstetrics and Gynecology, UAB,

Birmingham, USA

K. Harris

Division of Hematology, Department of Medicine,

UAB, Birmingham, USA

123

Arch Gynecol Obstet

DOI 10.1007/s00404-012-2422-3

considered in order to avoid cutting into vascular layers.

Vaginal delivery is preferred if feasible, and cesarean

delivery is reserved for usual obstetric indications. This

approach minimizes bleeding complications. Severe fetal

thrombocytopenia is an indication for a cesarean section

since vaginal delivery may be associated with traumatic

cerebral hemorrhage. However, fetal thrombocytopenia is

very rare in the case of ITP because, as in the case pre-

sented here, platelet antibodies are primarily of the IgM

type, which do not cross the placenta in clinically relevant

amounts [6].

Severe thrombocytopenia is also considered a contra-

indication to regional anesthesia. However, the etiology of

this patient’s thrombocytopenia was associated with giant

platelets (GP) that are produced by megakaryocytes in the

bone marrow in response to cytokine-driven up-regulation

of platelet production. The literature indicates that GP have

clinically normal hemostasis, even in the presence of

marked thrombocytopenia [7, 8]. Without recognition of

the misleading nature of the automated platelet count and

our patient’s true coagulation status, both obstetrical and

anaesthesiological management would have been modified.

This could potentially have introduced unwarranted risks to

the patient. Using this case, we hope to illustrate a diag-

nostic and therapeutic approach that may be adopted by

others.

Conflict of interest None.

References

1. Karim R, Sacher RA (2004) Thrombocytopenia in pregnancy. Curr

Hematol Rep 3:128–133

2. Michelson A (2008) The clinical approach to disorder of platelet

number and function, platelets, 2nd edn. In: Oxford AM. Elsevier,

UK, pp 825–830

3. Frolich MA, Gibby G, Mahla ME (2003) Thromboelastography to

assess coagulation in the thrombocytopenic parturient. Can J

Anaesth 50:853

4. Sharma S (2009) Hematologic and coagulation disorders, Chest-

nut’s obstetric anesthesia. In: Chestnut DH, Polley LS, Tsen LC,

Wong CA (eds) Mosby/Elsevier, Philadelphia, pp 943–960

5. van Veen JJ, Nokes TJ, Makris M (2010) The risk of spinal

haematoma following neuraxial anaesthesia or lumbar puncture in

thrombocytopenic individuals. Br J Haematol 148:15–25

6. Ben-Hur H, Gurevich P, Elhayany A, Avinoach I, Schneider DF,

Zusman I (2005) Transport of maternal immunoglobulins through

the human placental barrier in normal pregnancy and during

inflammation. Int J Mol Med 16:401–407

7. Furie B, Furie BC (2007) In vivo thrombus formation. J Thromb

Haemost 5(Suppl 1):12–17

8. Thompson CB, Jakubowski JA, Quinn PG, Deykin D, Valeri CR

(1984) Platelet size and age determine platelet function indepen-

dently. Blood 63:1372–1375

Fig. 1 Blood smear

Arch Gynecol Obstet

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