Thrombocytopenia is common (up to 12%) in pregnancy; thrombotic thrombocytopenia is a rare cause of thrombocytopenia; however, it is immediately life-threatening to both mother and fetus and requires immediate intervention. This is compounded by the need to act on a presumptive diagnosis with high level of suspicion given the relatively long laboratory confirmation time. A 31-year-old gravida 3, para 1 parturient at 26 weeks of gestation presented to outside hospital with recent onset of easy bruising and blurry vision. A blood count was drawn and showed a platelet count of 19,000/μL. She was transferred to our institution for management where an initial diagnosis of preeclampsia with severe features was made based on thrombocytopenia and fetal growth restriction (<1%). Platelet count nadired at 14,000/μL and a blood smear showed schistocytes, suggesting microangiopathic hemolysis, prompting discussion of urgent cesarean delivery and anesthesia consult. An urgent hematology consult led to presumptively diagnosing thrombotic thrombocytopenic purpura and cesarean delivery was deferred after discussion with the patient and team. Plasma exchange and steroid therapy were started promptly, and her platelet count improved within 12 hours. Unfortunately, the patient experienced neonatal demise. Undetectable ADAMTS13 levels confirmed diagnosis of thrombotic thrombocytopenia. She was transitioned to rituximab, platelets recovered to baseline, and she continues to do well. Thrombotic thrombocytopenia is a rare, life-threatening cause of thrombocytopenia in pregnancy. Despite grim fetal prognosis, especially in early pregnancy, low threshold of suspicion, early anesthesia involvement, and multi-disciplinary approach can facilitate diagnosis and timely intervention. In our case, it was likely lifesaving.

Thrombocytopenia is common (up to 12%) in pregnancy; thrombotic thrombocytopenia is a rare cause of thrombocytopenia; however, it is immediately life-threatening to both mother and fetus and requires immediate intervention. This is compounded by the need to act on a presumptive diagnosis with high level of suspicion given the relatively long laboratory confirmation time. A 31-year-old gravida 3, para 1 parturient at 26 weeks of gestation presented to outside hospital with recent onset of easy bruising and blurry vision. A blood count was drawn and showed a platelet count of 19,000/μL. She was transferred to our institution for management where an initial diagnosis of preeclampsia with severe features was made based on thrombocytopenia and fetal growth restriction (<1%). Platelet count nadired at 14,000/μL and a blood smear showed schistocytes, suggesting microangiopathic hemolysis, prompting discussion of urgent cesarean delivery and anesthesia consult. An urgent hematology consult led to presumptively diagnosing thrombotic thrombocytopenic purpura and cesarean delivery was deferred after discussion with the patient and team. Plasma exchange and steroid therapy were started promptly, and her platelet count improved within 12 hours. Unfortunately, the patient experienced neonatal demise. Undetectable ADAMTS13 levels confirmed diagnosis of thrombotic thrombocytopenia. She was transitioned to rituximab, platelets recovered to baseline, and she continues to do well. Thrombotic thrombocytopenia is a rare, life-threatening cause of thrombocytopenia in pregnancy. Despite grim fetal prognosis, especially in early pregnancy, low threshold of suspicion, early anesthesia involvement, and multi-disciplinary approach can facilitate diagnosis and timely intervention. In our case, it was likely lifesaving.

We retrospectively report the first use of intrathecal morphine prior to incision in two male patients undergoing a complex aortic reconstruction, who required complete circulatory arrest under deep hypothermia for intraoperative and postoperative pain control. We administered intrathecal morphine to two male patients undergoing circulatory arrest and deep hypothermia. Patients were fully heparinized prior to cardiopulmonary bypass. Deep hypothermic circulatory arrest was performed by cooling the patients to 18degrees C. Following the surgery, the neurologic status was monitored. The management of postoperative pain is a quality standard in health care. During the first 24 hours after surgery, we observed excellent analgesia without the associated side effects, thus, reducing the time required for pain control by the nursing staff. A successful analgetic strategy not only enhances the patient satisfaction, but may improve the postoperative outcome. However, complications, such as increased risk of epidural hematoma formation, are of special concern in cardiac surgery.
Analgesia ; Anesthesia, Spinal ; Cardiac Surgical Procedures ; Cardiopulmonary Bypass ; Circulatory Arrest, Deep Hypothermia Induced ; Delivery of Health Care ; Hematoma ; Heparin ; Humans ; Hypothermia ; Male ; Morphine ; Nursing Staff ; Pain, Postoperative ; Patient Satisfaction ; Retrospective Studies ; Thoracic Surgery