Anesthetic Mx of a pregnant lady with pure red cell aplasia:
Pure red cell disorder is an uncommon disorder in which maturation arrest occurs in the maturation of erythrocytes. Erythroblats are virtually absent in the bone marrow. Surgery poses a very high-risk for these patients because of the several complications that can occur in the perioperative period.

In this case report, published in the Journal of the Scientific Society, the authors report a pregnant patient with a pure red cell aplasia who was optimized pre-operatively and underwent cesarean section under sub-arachnoid block.

A 32-year-old female a known case of pure red cell aplasia since 2 years presented with full term pregnancy for safe institutional delivery. She underwent a series of investigations to evaluate the cause of anemia. The investigations were carried out to rule out thalassemia, glucose-6-phosphate dehydrogenase (G6PD) deficiency, sickle cell anemia, and multiple myeloma. Coomb's test, acid ham test, sucrose lysis test, paroxysmal nocturnal hemoglobinuria (PNH), anti-MIRL (CD59), anti-DAF (CD55) tests, and urine bence jones proteins were performed and all reports were negative. The diagnosis of pure red cell aplasia was made on these findings.

Serum erythropoietin - >2000 mIU/ml (8.9-29.5 mIU/ml), vitamin B 12 -1039 pg/ml (200-950 pg/ml), red cell folate -720ng/ml (175-700 ng/ml), at the time of admission her hemoglobin was 3.2 g/dl. She was transfused with 12 points of blood after diagnosing pure red cell aplasia. One year later she conceived. She came to hospital with complains of amenorrhea. Her pregnancy was diagnosed and confirmed by ultrasonographic studies.

At the time of cesarean section her hemoglobin was 10.8 g% hematocrit 32.7%, white blood cells (WBC) count 10,700 cells/mm 3 , platelet count 1.2 lakhs/mm 3 , erythrocyte sedimentation rate (ESR) 22 mm at the end of 1 h. Reticulocyte count was 0.8%, RBC 3.74 million/mm 3 , mean corpuscular volume (MCV) 87.2 fl, MCH 28.8 pg, mean corpuscular hemoglobin concentration (MCHC) 33%, red blood cell distribution width (RDW) 12.6%.

It was decided to manage the case by giving sub-arachnoid block. Sub-arachnoid block was given under strict asceptic pre-caution using 23 gauge quincke spinal needle in L3-L4 sub-arachnoid space and 1.8 cc of 0.5%(H) bupivacaine was injected after confirmation of free flow of cerebrospinal fluid (CSF). Monitoring included a continuous electrocardiogam, non-invasive blood pressure, oxygen saturation, respiratory rate, and urine output. The surgery was uneventful and lasted for 60 min.

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