2008;62:452C5. and metoclopramide 10 mg. After attaching standard monitoring, two wide bore IV cannulae were inserted. After pre-oxygenating the patient for 3 min, anaesthesia was induced with rapid sequence induction with thiopentone 250 mg and succinylcholine 75 mg, followed by oral intubation. Anaesthesia was maintained with isoflurane in 50% oxygen: Nitrous oxide mixture and intermittent administration of vecuronium as and when required. Tranexamic acid 500 mg was injected slowly. A 2.7 kg baby was delivered within 10 min with APGAR score 9 and 10 at 1 and 5 min, respectively. Fentanyl 100 g and midazolam 1 mg were injected. Oxytocin 20 U in 500 ml of 0.9% saline was started and Protodioscin IV methylergometrine 0.2 mg was given. Intraoperative haemodynamics was stable. Total blood loss was 1.2 L. The patient was extubated on the table. Post-operative steroids were continued and her platelet count improved. There was no neonatal thrombocytopaenia or haemorrhagic complications. Post-operative pain was managed with pentazocine. Both mother and baby were discharged on day 3. Although the incidence of ITP is 5% among pregnant patients, severe thrombocytopaenia (platelet count 50,000/mm3) is rare.[1] There are autoantibodies against the platelet membrane glycoproteins. Exacerbation of thrombocytopaenia is known to occur in pregnancy and peripartum haemorrhage is very common in these patients.[2] Foetal and neonatal thrombocytopaenia and intraventricular bleed are possibilities but not very common.[2] Management of severe thrombocytopaenia in ITP requires platelet transfusion before surgery. Protodioscin IV immunoglobulins 1 g/kg reduce platelet destruction, but it is expensive and was not available with us.[1,2,3,4,5] Perioperative methylprednisolone 1 g along with pre-operative 8 RDP transfusion covered the perioperative period. Since the surgery was emergency, platelet count was not repeated. Each unit of RDP is assumed to increase the Protodioscin platelet count by 3000C5000 units/mm3. Thromboelastography can help us in this scenario, but it was not available with us. Tranexamic acid, an antifibrinolytic, helps to reduce operative blood loss and blood transfusions.[6] The intraoperative uterine contraction was confirmed with oxytocin and methylergometrine. Non-steroidal anti-inflammatory drugs (NSAIDs) including paracetamol were avoided. Protodioscin No intramuscular injections were given. Post-partum haemorrhage was not seen in our patient. Anaesthesia goals in management of pregnant patient with severe thrombocytopaenia must include institution of general anaesthesia, platelet transfusion preferably single donor to prevent allo-immunisation, IV immunoglobulins or steroids to reduce platelet destruction, maternal and foetal/neonatal monitoring for haemorrhagic complications, abstinence from Protodioscin use of NSAIDs or other platelet lowering Rabbit polyclonal to AFF2 drugs and avoidance of airway trauma, nasal intubations and intramuscular injections. The maternal and foetal outcomes are good with appropriate management. REFERENCES 1. Parnas M, Sheiner E, Shoham-Vardi I, Burstein E, Yermiahu T, Levi I, et al. Moderate to severe thrombocytopenia during pregnancy. Eur J Obstet Gynecol Reprod Biol. 2006;128:163C8. [PubMed] [Google Scholar] 2. Borna S, Borna H, Khazardoost S. Maternal and neonatal outcomes in pregnant women with immune thrombocytopenic purpura. Arch Iran Med. 2006;9:115C8. [PubMed] [Google Scholar] 3. Devendra K, Koh LP. Pregnancy in women with idiopathic thrombocytopaenic purpura. Ann Acad Med Singapore. 2002;31:276C80. [PubMed] [Google Scholar] 4. Karne V, Patil M. Severe thrombocytopenia in an immune thrombocytopenic parturient non-responder to medical line of treatment: Anaesthetic management for splenectomy combined with caesarean section. Indian J Hematol Blood Transfus. 2012;28:54C7. [PMC free article] [PubMed] [Google Scholar] 5. Varghese L, Viswabandya A, Mathew AJ. Dapsone, danazol, and intrapartum splenectomy in refractory ITP complicating pregnancy. Indian J Med Sci. 2008;62:452C5. [PubMed] [Google Scholar] 6. Tay S, Szabo F, Spain B. Dental extraction in a child with chronic idiopathic thrombocytopenia purpura: Are preoperative platelet transfusions necessary? A A Case Rep. 2013;1:3C4. [PubMed] [Google Scholar].