Hyperimmune thrombocytopenia in pregnancy treated by splenectomy.

3 cases of hyperimmune thrombocytopenia in pregnancy are described. Splenectomy was followed by return of the platelet count to normal in all. There was no maternal or fetal death. Liam G. O’Connell, MD, MSc, Consultant Haematologist, St. Vincent’s Hospital, Elm Park, Dublin 4 (Ireland) Hyperimmune thrombocytopenia (HTP) in pregnancy represents a hazard to both mother andfetus. Prednisone is the treatment of choice but may be ineffective when HTP occurs inpregnancy. Splenectomy offers an early alternative in severe cases.Case ReportsCase IA 20-year-old woman who had a previous normal pregnancy presented at 20 weeks gestationwith severe epistaxis and purpura after rubella exposure. Haemoglobin was 9.5 g/dl and theplatelet count was 4 X 10V1. Increased immature megakar-yocytes were seen on marrowaspiration. Rubella HAI titre was 320 and subsequently fell to 10. Bleeding continuedunresponsive to transfusion of 12 U of platelet concentrate and splenectomy was performed.Bleeding ceased thereafter and the platelet count returned to normal in 10 days. A full-terminfant who did not develop thrombocytopenia was later delivered.Case IIA 37-year-old woman with eight previous pregnancies presented at 36 weeks gestation. Herplatelet count was 12 X 109/1, haemoglobin 12 g/dl, and she had wide-316FitzGerald/McCarthy/O’Connell/McCannspread purpura. Antibody screen was negative. A marrow aspirate showed increased immaturemegakaryocytes. Despite prednisone 60 mg/day her platelets fell to 6 X 10V1, accompanied bysevere epistaxis over the next 5 days. The splenic pedicle was clamped with peroperative platelettransfusion and a 3,000 g infant was delivered by Caesarian section. A splenectomy was thenperformed. Cord blood platelets were 11 X 108/1. The baby’s count was 95 × 10VI, which fell to 30 X lO < > /l on the 3rd day after delivery, but returned to normal 2 days later. The mother’splatelets were normal 7 days post-operatively and have remained so since.Case IIIA 30-year-old woman who had two previous pregnancies presented with purpura of her lowerlimbs at 20 weeks gestation and a history of rubella exposure. Her platelet count was 66 X 10β/l,and a marrow aspirate showed increased immature megakaryocytes. Therapy with prednisone 80mg/day was initiated. Her platelet count steadily decreased and she presented 3 weeks later withsevere purpura, epistaxis and gingival bleeding, her platelet count being 1 X 10V1. Asplenectomy was performed under platelet cover and her count returned to normal over 2months. She gave birth to twins at term who had stigmata of congenital rubella.DiscussionHTP may present or worsen in pregnancy. It is a rare complication and reports are anecdotal.Corticosteroids alone rarely achieve remission [1] and represent a small theoretical hazard to thefetus [2]. As splenectomy has become safer with the availability of platelet transfusions, it hasbecome an early alternative in severe thrombocytopenia.Thrombocytopenia results in a high fetal and neonatal loss although maternal mortality is low[3]. Elective Caesarian section may minimize fetal trauma and in extreme circumstances may becombined with splenectomy as described.ReferencesLaros, R. K. and Sweet, R. L.: Management of idiopathic thrombocytopenic purpura inpregnancy. Am. J. Obstet. Gynec. 122: 191–192 (1974).Janerich, D. T.; Piper, J. M., and Glebatis, D. M.: Hormones and limb deformities. Lancet ii: 96–97 (1973).