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LETTERS TO EDITOR
Year : 2020  |  Volume : 10  |  Issue : 2  |  Page : 145-146

Thrombocytopenia in COVID parturients: Is less more of a concern?


Department of Anaesthesiology, Pain Medicine and Critical Care, AIIMS, New Delhi, India

Date of Submission02-Jul-2020
Date of Acceptance03-Jul-2020
Date of Web Publication20-Aug-2020

Correspondence Address:
Dr. Sulagna Bhattacharjee
Room No. 5011, 5th Floor, Teaching Block, AIIMS, New Delhi - 110 049
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacc.JOACC_60_20

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How to cite this article:
Priyanka T N, Gupta A, Bhattacharjee S. Thrombocytopenia in COVID parturients: Is less more of a concern?. J Obstet Anaesth Crit Care 2020;10:145-6

How to cite this URL:
Priyanka T N, Gupta A, Bhattacharjee S. Thrombocytopenia in COVID parturients: Is less more of a concern?. J Obstet Anaesth Crit Care [serial online] 2020 [cited 2020 Nov 27];10:145-6. Available from: https://www.joacc.com/text.asp?2020/10/2/145/292749



Dear Sir,

Novel corona virus disease (COVID-19) is a pandemic affecting 216 countries/regions and more than 10 million people globally.[1] According to the UNICEF, an estimated 116 million babies will be born under the shadow of COVID 19, with India expecting to have one of the highest births (20.1 million).[2] Although pregnancy does not appear to alter the clinical course of COVID 19 disease, with most parturients presenting with mild to moderate symptoms,[3] effective multidisciplinary peripartum and perinatal care remains a challenge in these times. Thrombocytopenia is commonly reported in COVID 19 patients, approximately 36%,[4] and has also been reported in pregnant patients with mild COVID.[5] Apart from the proposed multifactorial causes, like decreased platelet production, immune-mediated platelet destruction, and increased platelet consumption by microthrombi generation,[6] thrombocytopenia in COVID-positive pregnant patients can be exaggerated by obstetric factors like gestational thrombocytopenia or pre-eclampsia.[5]

A 38-years-old 39 weeks+ pregnant female with a precious pregnancy (G4P3A3, IVF conception) was scheduled for cesarean section in our tertiary care COVID facility. She was also a known case of rheumatic heart disease with moderate mitral stenosis, with a history of percutaneous mitral commissurotomy and hypothyroidism. She was diagnosed to have mild COVID-19, presenting with fever and sore throat. She was NYHA 1 throughout pregnancy. Preoperative investigations of significance were a normal lung ultrasound, mitral valve area of 1.5 cm2, a platelet count of 90,000/cmm, with normal prothrombin time and activated partial thromboplastin time, which abruptly dropped to 74,000 within 24 hours, the night before surgery. Considering therapidly falling trend of platelets, we decided to transfuse her four units of random donor platelets, following which the platelet count rose to 84,000/cmm. We opted for a low-dose, single-shot spinal block, through a 27-gauge spinal needle, with intrathecal morphine (hyperbaric bupivacaine 7.5 mg with 100 microgram (μg) morphine and 10 μg fentanyl) along with invasive blood pressure monitoring. Perioperatively, the patient developed hypotension and bradycardia, which was managed with vasopressors (noradrenalin and phenylephrine) and atropine.

Regional anesthesia is a clear winner over general anesthesia for cesarean section in COVID-positive cesarean sections. It can prevent the development of, or the exacerbation of pulmonary complications of COVID 19 disease as well as avoid high-risk aerosol generating procedures of intubation and extubation.[7] Also, neuraxial anesthesia does not appear to alter the recovery of parturients from COVID 19 disease.[7] In our case, avoidance of the epidural needle and catheter reduced the chances of a traumatic tap with subsequent hematoma formation which was a possibility in case COVID progressed from mild to severe disease. Intrathecal morphine, along with paracetamol, provided adequate postoperative analgesia for the next two days, thereby preventing pain-induced tachycardia. The mother and the newborn were discharged in good health.

Thrombocytopenia in a parturient with COVID-19 can leave the obstetric anesthesiologist with an uncomfortable dilemma. Also, a falling platelet count can serve as a clinical indicator of worsening COVID during hospitalization.[8] Thus, it is of utmost importance, that we closely monitor the platelet levels and its trend in the preoperative period. In a time, when most blood banks are running dry, a backup of donor platelets arranged pre-emptively may be warranted for the safe conduct of regional anesthesia.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Corona virus disease (COVID-19) pandemic. World Health Organisation. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019?gclid=Cj0KCQjwoub 3BRC6ARIsABGhnya9pMtb1uaisZhYYkuQ_o2ebLtUt6W 3kYbyvYcplsDVbtwPB4gpdoaAqI0EALw_wcB. [Last accessed on 2020 Jun 29].  Back to cited text no. 1
    
2.
Pregnant mothers and babies born during COVID-19 pandemic threatened by strained health systems and disruptions in services. UNICEF. Available from: https://www.unicef.org/press-releases/pregnant-mothers-and-babies-born-during-covid-19-pandemic- threatened-strained-health. [Last accessed on 2020 Jun 29].  Back to cited text no. 2
    
3.
Qiancheng X, Jian S, Lingling P, Lei H, Xiaogan J, Weihua L, et al. Coronavirus disease 2019 in pregnancy. Int J Infect Dis 2020;95:376-83.  Back to cited text no. 3
    
4.
Guan Wj, Ni Zy, Hu Y, Liang WH, Ou CQ, He JX, et al. China Medical Treatment Expert Group for Covid-19. Clinical characteristics of Coronavirus Disease 2019 in China. N Engl J Med 2020;382:1708-20.  Back to cited text no. 4
    
5.
Gouez AL, Vivanti AJ, Benhamou D, Desconclois C, Mercier FJ. Thrombocytopenia in pregnant patients with mild COVID-19. Int J Obstet Anesth 2020. doi: 10.1016/j.ijoa. 2020.05.010.  Back to cited text no. 5
    
6.
Xu P, Zhou Q, Xu J. Mechanism of thrombocytopenia in COVID-19 patients. Ann Hematol 2020;99:1205-8.  Back to cited text no. 6
    
7.
Chen R, Zhang Y, Huang L, Cheng BH, Xia ZY, Meng QT. Safety and efficacy of different anesthetic regimens for parturients with COVID-19 undergoing caesarean delivery: A case series of 17 patients. Can J Anaesth 2020;67:655-63.  Back to cited text no. 7
    
8.
Lippi G, Plebani M, Henry BM. Thrombocytopenia is associated with severe coronavirus disease 2019 (COVID-19) infections: A meta-analysis. Clin Chim Acta 2020;506:145-8.  Back to cited text no. 8
    




 

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