Rosh Review A1.3

A 32-year-old woman who is at 20 weeks gestational age presents to the ED after a seizure. Her vital signs are BP 115/70, HR 105, RR 16, T 98.7°F, and pulse oximetry 98% on room air. On exam, you note some confusion, but otherwise there are no focal deficits. Lab results reveal a hemoglobin of 7 g/dL and platelets of 12,000/microliter. A peripheral blood smear reveals schistocytes. Which of the following is the most appropriate treatment for her condition?

A. Delivery of fetus

B. Magnesium sulfate

C. Plasmapharesis

D. Platelet transfusion

The patient has thrombotic thrombocytopenic purpura (TTP). The classic pentad of TTP includes CNS abnormalities, renal pathologyfevermicroangiopathic hemolytic anemia, and thrombocytopenia. However, diagnostic criteria have recently been simplified to include all adults with microangiopathic or microvascular hemolytic anemia and thrombocytopenia with no other explanation for these findings. TTP shares many clinical and laboratory features as HELLP syndrome. HELLP syndrome is less common before 24 weeks gestation and the derangements in hemoglobin and platelet levels are more severe in TTP. The treatment mainstay of treatment for TTP is plasmapheresis (plasma exchange), which can achieve remission of disease in 80% of patients. If plasmapheresis cannot be immediately performed, fresh frozen plasma (FFP) should be administered, until pheresis can be performed.

The patient’s fetus is nonviable at 20 weeks gestation (A) and cannot be delivered. If the fetus is viable, delivery is an option. However, the patient is at high risk for bleeding complications and medical therapy and plasmapheresis is the first line of treatment. Magnesium sulfate (B) is used in the treatment of eclampsia. Although this patient had a seizure, her blood pressure is normal and her lab results are more consistent with TTP than eclampsia. While platelet levels are low in TTP,platelet transfusion (D) is reserved only for patients with life-threatening bleeding. Any administration of platelets will result in destruction from platelet aggregation in the microvascular circulation.

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