Case 21 – update 1

Thanks for all of your suggestions. We have a bit more information for you.

Our patient is normally fit and well and delivered her first baby a week ago.  She had suffered from iron deficiency during pregnancy but didn’t tolerate iron tablets. She was placed on prophylactic LMWH from the obstetric team for seven days post partum owing to her BMI (as per RCOG Green Top Guidelines on thromboprophylaxis).  She has been bleeding since giving birth and has noted some discharge.  She states it’s like her normal period.  She also noted a rash on her legs and blood blisters in her mouth.She had an episiotomy during labour and thinks the wound may be infected.  She’s said she had chills earlier on in the day.

On examination her obs showed: pulse 110bpm, BP 118/82, RR 20/min, SpO2 96% RA and temp 37.5oC.  She had a rash on her legs and looked pale.  She had a mildly tender abdomen  but no guarding or rebound.

Image

Blood tests reveal:

FBC is repeated and same results as previous.

The film comment is: “Microcytic, hypochromic anaemia with a dimorphic population.  Occasional pencil cell. No red cell fragments. Neutrophils display left shift.  Thrombocytopenia is confirmed with no platelet clumping”.

LFTs: ALT 36iu/L, ALP 85iu/L, albumin 32g/L, bilirubin 15μmol/L

U&E: Na 146mmol/L, K 4.3mmol/L, creat 67μmol/L, urea 8.9mmol/L

CRP 79mg/L

Coag: PT 13s, APTT 32s, fibrinogen 5.9g/L

She is started on antibiotics in A&E for presumed sepsis and an obstetric opinion is sought.

Questions:

1) What are the differential diagnoses of thrombocytopenia in pregnancy

2) Your consultant thinks to give some platelets. Do you agree?

3) Is the baby at risk?

Please reply on Twitter and always include #teamhaem to allow others to follow your comments. Please join in the debate and learn about haematological problems along the way. The case will continue to  evolve over the coming week so keep checking #teamhaem for more information.

Please note – all cases on TeamHaem are entirely fictional to protect patient confidentiality.

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