Balancing Maternal Risk in Refractory ITP: Safety & Systems Errors with Remifentanil PCA

for Labor Analgesia

Kimberly Peloza, MD, Lauren Blake MD, Naola Austin MD, Phillip Callihan MD, PhD

Department of Anesthesiology, Perioperative, and Pain Medicine · Stanford Health Care

Immune thrombocytopenic purpura (ITP) affects approximately 1-3 in 10,000pregnancies

Low platelet counts associated with ITP present challenges for offering neuraxial analgesia during labor

Alternative anesthetic strategies include remifentanil PCA for labor analgesia or cesarean delivery under general

anesthesia

Medical History and Pregnancy

42-year-old G1P0 at 17w presented to the ED with epistaxis, easy bruising, and petechiae was diagnosed with ITP

ITP managed with prolonged steroid taper, weekly IVIG, romiplostim, and splenectomy

At 32 weeks, patient was seen by anesthesia pre-op clinic and elected for planned cesarean under GA 

Labor

At 35+6 weeks, patient presented with PPROM and a platelet count of 131,000

Patient elected for labor augmentation with remifentanil PCA

Uncomplicated SVD with QBL 484mL

Immediately postpartum, IV bolus was started for fever and tachycardia

Patient was found unresponsive, hypoxemic, and with no palpable carotid pulse

Code blue called and patient was bagged to normal oxygen saturations with return of palpable pulses and consciousness

Broad work up, including POCUS, was negative

Obstetric Code Blue

Accidental remifentanil bolus is a possible cause of sedation and respiratory depression

Dose-dependent respiratory arrests occur in laboring patients

This case highlights the importance of robust systems-level safety mechanisms

Shared Decision Making

Demonstrates the value of shared decision making during medically complex pregnancies