Poster Presentation Society of Obstetric Medicine of Australia and New Zealand ASM 2015

Successful multidisciplinary management of aplastic anaemia diagnosed in pregnancy  (#211)

Rebecca Still 1 , Briony Cutts 1 , Andrea Khaw 1 , Shaun Brennecke 1
  1. Maternity Services, Royal Womens Hospital, Melbourne, Victoria, Australia

Aplastic anaemia is a rare and life-threatening medical disorder characterised by bone marrow hypoplasia and peripheral pancytopaenia. Diagnosis during pregnancy is rare, and with a maternal mortality rate of 20-60%, discussion of such cases is warranted.

We report a case of aplastic anaemia, diagnosed at 14 weeks gestation, in a 38 year old gravida 3 para 2.  On routine antenatal screening tests, haematological examination revealed pancytopaenia. After initial diagnosis in Launceston, Tasmania, the patient was transferred for tertiary level, multidisciplinary, perinatal care to Melbourne where bone marrow biopsy revealed aplastic anaemia and flow cytometry showed a paroxysmal nocturnal haemoglobinuria clone of 0.3%.

Her past obstetric history included a previous normal vaginal delivery in 1995 and a caesarean section for breech presentation in 2012. 

Antenatal management included regular blood and platelet transfusions, the immunosuppressive agent cyclosporin, granulocyte-colony stimulating factor to maintain neutrophil count and acyclovir for viral prophylaxis. The antenatal course was complicated by an episode of neutropaenic sepsis, but was otherwise relatively uneventful.  Fetal growth and welfare surveillance were satisfactory.

Co-morbidities for this patient with a BMI of 31 included gestational diabetes managed with insulin therapy, gastro-oesophageal reflux, irritable bowel syndrome and vancomycin-resistant enterococcus (Van A strain) colonisation.

Delivery was via planned caesarean section at 34 weeks gestation. Preoperative corticosteroids for fetal lung maturation were administered in the form of IV hydrocortisone, to avoid intra-muscular injection sepsis and haematoma risks. The surgery was uneventful, with good maternal recovery and neonatal outcome. Post-operatively, platelet transfusions and tranexamic were administered to prevent bleeding. Venous thrombo-embolism prophylaxis was not required as the platelet count did not exceed 50. The infant (birthweight 1912g) was fed expressed breast milk during a short postnatal stay in the special care nursery.

Six months on, the patient remains well and is preparing for a bone marrow transplant. The infant is thriving.