Background:
Insertion and removal of epidural catheters in severe thrombocytopenia run the risk of epidural haematomas.  In immune thrombocytopenia (ITP), platelet transfusion may be ineffective due to rapid platelet destruction.  We present a case report in which an epidural catheter was inserted in an obstetric patient with ITP and its management.

Case Report:
A 38 year old lady in term labour requested for analgesia.  Her antenatal and medical history was uneventful.  As her platelet count at her booking visit and at 1.5 months prior did not reveal any thrombocytopenia, she received a lumbar combined spinal-epidural.  The epidural space was found using loss of resistance to saline with an 18 gauge Tuohy needle and intrathecal space entered with a 27 gauge Whitacre needle.  Subsequently, a full blood count showed severe thrombocytopenia (38,000 per microliter) and was confirmed by a repeated result of 26,000.  The patient had no history of bleeding tendencies.  Examination was negative for haemorrhage, neurological deficits or bruising at the epidural site.  Vaginal delivery had blood loss of 300ml.
Her lower limbs’ neurological status was monitored.  Haematology diagnosed ITP and started oral Prednisolone 60 mg/day.  A unit of pooled platelets was given with platelets rising to 74,000 and a second unit given before catheter removal.  48 hours of monitoring was negative for neurological deficits or signs of an epidural haematoma.

Discussion:
ITP causes autoimmune platelet destruction.  Epidural hematoma risk from neuraxial procedure in parturients with platelets ≥ 70,000 is 0.2% but unclear at lower levels and estimated at 3% for 50,000 to 69,000 and 11% for ≤ 49,000.
ITP therapy (steroids) has slow onset (5 days).  IV immunoglobulin has faster onset (2 days) but reserved for severe bleeding.  Recovery of platelet levels is unpredictable for both.
Platelet transfusion is reserved for severe bleeding as destruction is rapid and platelet rise is unpredictable.  In this case, transfusion produced a rise in platelets adequate for catheter removal. However, delayed neuraxial bleeding may occur.

Learning points:
Epidural catheter removal in ITP is challenging due to unpredictable and slow effect of therapy on platelet count. Transfused platelets are rapidly destroyed. By monitoring platelet counts after transfusion and vigilance, this case shows the use and removal of an epidural in severe thrombocytopenia from ITP.

11 / Epidural management in a parturient with severe immune thrombocytopenia_x000D_