Gebelikte intrauterin exitusla sonuçlanan şiddetli trombositopeni ve literatürün gözden geçirilmesi

Amaç: Şiddetli trombositopeni ve intrauterin exitus fetusun eşlik ettiği bir gebeliği ve bunun yönetimini literatürü gözden geçirerek sunmayı amaçladık Olgu sunumu: 21 yaşında, 24 hafta tekil gebeliği olan hasta, bulantı, kusma, burun kanaması şikayeti ile başvurdu. TA: 110/ 70 mmHg, nabız: 85/ dk idi. Herhangi bir obstetrik patoloji saptanmayan hastada, şiddetli trombositopeni (plt: 9000/ uL) saptandı. Hb: 13 g/ dl, ALT: 12 U/ L, AST: 40 U/ L, Albumin: 2,47 g/ dl, kreatinin: 0,83 mg/dl, total biluribin: 0,27 mg/dl idi ve immün trombositopeni ön tanısı ile, 1 Ü aferez ve 1 Ü havuzlanmış trombosit transfüzyonu ve 32 mg/gün prednol tedavisi uygulandı; kontrol plt: 36000/ uL idi. Hastanın 10 gün sonraki kontrolünde, plt: 6000/ uL ve fetal kalp atımı izlenmemesi üzerine, terminasyon kararı verildi. Vital bulgular: TA: 130/ 80, nabız: 98/ dk, ateş: 36 0C idi. Hb:6,7 g/ dl, plt: 6000/ uL, total biluribin 0,88 mg/ dl, ALT: 28 U/ L, AST: 70 U/ L, LDH: 2297 U/L, Haptoglobin <10 mg/dl, INR: 0,94, Albumin: 2,47 g/dl, kreatinin: 0,83 mg/dl, direct coombs:-, indirect coombs:-, TİT: protein 4+ idi. Hastaya mikroanjioptik hemolitik anemi tanısıyla, 4 Ü aferez trombosit, 3 Ü ES, 30 gr İVİG, 120 mg prednol uygulandı. Plt: 59000 /uL olduğunda, doğum indüksiyonuna başlandı. İndüksiyon sırasında, plazmaferez uygulandı ve 6 saat sonra vajinal yolla doğum gerçekleşti. Sonuç: Gebelikte şiddetli trombositopeni saptanan hastaların, nedene yönelik ayırıcı tanısı en kısa sürede yapılmalıdır. Maternal mortalite riski nedeniyle gebeliğin acil sonlandırılması gerekebilir. Karmaşık ve kritik vakalarda, multidisipliner bir ekip yaklaşımının kullanılması ile daha etkili sonuç alınabilir.

Anahtar Kelimeler:

trombositopeni, TTP, gebelik, ADAMTS13

Severe thrombocytopenia resulting in intrauterine exitus in pregnancy and review of the literature

Objective: We aimed to present a pregnancy accompanied by severe thrombocytopenia and intrauterine exitus fetus and its management by reviewing the literature. Case report: A 21-year-old patient with a 24-week singleton pregnancy was admitted with the complaints of nausea, vomiting and epistaxis. TA: 110/70 mmHg, heart rate: 85/min. Severe thrombocytopenia (plt: 9000/uL) was found in the patient who did not have any obstetric pathology. Hb: 13 g/dl, ALT: 12 U/ L, AST: 40 U/ L, Albumin: 2.47 g/dl, creatinine: 0.83 mg/dl, total bilirubin: 0.27 mg/dl, and with the preliminary diagnosis of immune thrombocytopenia, 1 U apheresis and 1 U pooled platelet transfusion and 32 mg/day prednol treatment were applied; control plt was 36000/uL. At the patient's follow-up 10 days later, plt: 6000/uL and fetal heart rate were not observed, so termination was decided. Vital signs: TA: 130/80, heart rate: 98/min, fever: 36 0C. Hb: 6.7 g/ dl, plt: 6000/ uL, total bilirubin 0.88 mg/ dl, ALT: 28 U/ L, AST: 70 U/ L, LDH: 2297 U/L, Haptoglobin <10 mg/ dl, INR: 0.94, Albumin: 2.47 g/dl, creatinine: 0.83 mg/dl, direct coombs:-, indirect coombs:-, urinary analysis: protein 4+. With the diagnosis of microangioptic hemolytic anemia, the patient was administered 4 U apheresis platelets, 3 U ES, 30 g IVIG, 120 mg prednol. When plt: 59000 /uL, labor induction was started. During induction, plasmapheresis was applied and vaginal delivery occurred 6 hours later. Conclusion: The differential diagnosis of patients with severe thrombocytopenia during pregnancy should be made as soon as possible. Immediate termination of pregnancy may be required due to the risk of maternal mortality. In complex and critical cases, more effective results can be obtained by using a multidisciplinary team approach.

Keywords:

thrombocytopenia, TTP, pregnancy, ADAMTS13,

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