A 27-year-old woman, gravida 1 para 0, at 28 weeks gestation comes to the office for a routine prenatal visit. Her initial prenatal laboratory results at 12 weeks gestation were as follows: The patient reports no vaginal bleeding, leakage of fluid, or contractions. There is good fetal movement. She has increasing urinary frequency and nocturia but no dysuria or hematuria. The patient has a history of tension headaches, which have become more frequent but resolve with acetaminophen. She has no other chronic medical conditions or previous surgeries. The patient works in a retirement home and reports leg swelling at the end of her shift. She is a vegetarian and takes a daily prenatal vitamin. She does not use tobacco, alcohol, or illicit drugs. Temperature is 37 C (98.6 F) , blood pressure is 128/76 mm Hg, and pulse is 86/min. BMI is 30 kg/m²; the patient has been gaining 0.5 kg (1.1 lb) a week during the pregnancy. The fetal heart rate is 152/min. Examination shows a uterus consistent with a 28-week gestation. There is trace lower extremity edema bilaterally. The patient has had no laboratory evaluations since her initial prenatal visit. The patient comes to the hospital at 38 weeks gestation in active labor and with spontaneous rupture of membranes. Blood pressure is 130/84 mm Hg and heart rate is 96/min. Fetal heart rate tracing is reassuring. Uterine contractions are regular and occur every 4 minutes. Cervical examination reveals 5-cm dilation, 100% effacement, and a vertex presentation at −1 station. Complete blood count on admission is as follows: The patient requests neuraxial labor analgesia.
Which of the following is the most appropriate next step in management of this patient?

Question

A 27-year-old woman, gravida 1 para 0, at 28 weeks gestation comes to the office for a routine prenatal visit. Her initial prenatal laboratory results at 12 weeks gestation were as follows:

The patient reports no vaginal bleeding, leakage of fluid, or contractions. There is good fetal movement. She has increasing urinary frequency and nocturia but no dysuria or hematuria. The patient has a history of tension headaches, which have become more frequent but resolve with acetaminophen. She has no other chronic medical conditions or previous surgeries. The patient works in a retirement home and reports leg swelling at the end of her shift. She is a vegetarian and takes a daily prenatal vitamin. She does not use tobacco, alcohol, or illicit drugs. Temperature is 37 C (98.6 F) , blood pressure is 128/76 mm Hg, and pulse is 86/min. BMI is 30 kg/m²; the patient has been gaining 0.5 kg (1.1 lb) a week during the pregnancy. The fetal heart rate is 152/min. Examination shows a uterus consistent with a 28-week gestation. There is trace lower extremity edema bilaterally. The patient has had no laboratory evaluations since her initial prenatal visit. The patient comes to the hospital at 38 weeks gestation in active labor and with spontaneous rupture of membranes. Blood pressure is 130/84 mm Hg and heart rate is 96/min. Fetal heart rate tracing is reassuring. Uterine contractions are regular and occur every 4 minutes. Cervical examination reveals 5-cm dilation, 100% effacement, and a vertex presentation at −1 station. Complete blood count on admission is as follows:

The patient requests neuraxial labor analgesia.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Pregnant women in active labor receive the most effective pain relief, with a low risk of adverse effects to the mother and fetus, from neuraxial analgesia. Contraindications to neuraxial analgesia in thrombocytopenic patients include severe thrombocytopenia (platelets <70,000/mm³) or rapidly dropping platelet count (often associated with preeclampsia with severe features). In these patients, there is an increased risk of spinal epidural hematoma. In this patient with a platelet count >100,000/mm³ and no evidence of platelet dysfunction (eg, bleeding, bruising), neuraxial analgesia can be administered safely. (Choice A) Desmopressin (ddAVP) is used in patients with von Willebrand disease to increase levels of von Willebrand factor and factor VIII. It is not indicated in the management of gestational thrombocytopenia. (Choice B) Intravenous labor analgesia is an option for those who have contraindications to neuraxial analgesia or prefer less invasive intervention. (Choice C) This patient has no indication for cesarean delivery (eg, breech presentation, fetal heart rate abnormalities). However, if she eventually requires a cesarean delivery, she qualifies for neuraxial analgesia due to a platelet count >100,000/mm³. (Choice E) Indications for platelet transfusion include a platelet count <10,000/mm³, active bleeding with a platelet count <50,000/mm³, or planned major surgery with a platelet count <50,000/mm³. Educational objective: Neuraxial analgesia provides the most effective pain relief for laboring patients with a low risk of adverse effects. Contraindications include severe thrombocytopenia or a rapidly dropping platelet count due to the risk of spinal epidural hematoma. References: Neuraxial anesthesia in parturients with thrombocytopenia: a multisite retrospective cohort study. (http://www.ncbi.nlm.nih.gov/pubmed/26378701)

A 27-Year-Old Woman, Gravida 1 Para 0, at 28 Weeks