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Thrombocytopenia in Pregnancy — FRCA Final MCQ

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HardObstetric AnaesthesiaThrombocytopenia in PregnancyFRCA Final

A 28-year-old primiparous woman at 39 weeks' gestation requests epidural analgesia in early labour. She has previously been assessed as having gestational thrombocytopenia. Her platelet counts were 86 × 10⁹/L at 36 weeks, 84 × 10⁹/L at 38 weeks and 82 × 10⁹/L four hours ago. She is normotensive, has no proteinuria, has normal liver enzymes and coagulation tests, takes no antithrombotic medication, and has no personal or family history of abnormal bleeding. What is the most appropriate course of action?

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Correct answer: A — Proceed with epidural insertion following senior review and documented risk–benefit discussion

The correct answer is A. This is stable, isolated gestational thrombocytopenia with a recent platelet count of 82 × 10⁹/L, no bleeding phenotype, no anticoagulant exposure and no evidence of pre-eclampsia, HELLP syndrome or another coagulopathy. Contemporary obstetric evidence indicates that the risk of neuraxial haematoma is very low at platelet counts of at least 70 × 10⁹/L in this setting; the decision should follow senior assessment and shared risk–benefit discussion rather than an inflexible threshold. Thromboelastography may provide supplementary information but is not required or validated as a mandatory clearance test. Remifentanil PCA is an alternative when neuraxial analgesia is contraindicated, which it is not here. Prophylactic platelet transfusion is unsupported and exposes the patient to transfusion risk. A further count is unnecessary given the recent result, established diagnosis and stable trajectory.

Reference: Bauer ME et al. The Society for Obstetric Anesthesia and Perinatology Interdisciplinary Consensus Statement on Neuraxial Procedures in Obstetric Patients With Thrombocytopenia. Anesthesia & Analgesia. 2021;132:1531–1544. https://pubmed.ncbi.nlm.nih.gov/32259875/