COVID-19 and coagulation abnormalities diagnostic dilemma

ABSTRACT

Background: Low platelets and fibrinogen levels at term are associated with pre-ecplampsia and abruption of placenta whilst congenital hypofibrogenemia in pregnancy is extremely rare, all have potential significant haemorrhagic consequences. We present a case of antepartum haemorrhage (APH), hypofibrinogenemia and thrombocytopenia on a background of a COVID-19 diagnosis. Aims: A 26 y, G3 P0 +2 miscarriages presented at 36 weeks with APH of 500 ml and positive PCR for Covid-19. She had an epidural sited for labour analgesia, her subsequent blood tests revealed thrombocytopenia (87) and a hypofibrogenemia of 0.5 g/dl despite normal platelets 12 weeks prior. She had an uneventful emergency caesarean necessitated by foetal compromise in labour (working diagnosis of placental abruption), 2 units of cryoprecipitate was transfused, blood loss was 600 ml and no abruption found. We monitored her for neurological recovery from the epidural block and delayed removal of epidural catheter until her post-partum fibrinogen was 1.5 g/dl and platelets 112 after discussion with haematology. She and her baby were discharged uneventfully on day two. Methods: The cause for this patient's severe hypofibrogenemia and associated thrombocytopenia was unclear at the time. Results: A normal platelet count earlier in her pregnancy suggests an acute or pregnancy related process. Pre-eclampsia and placental abruption were ruled out at c-section. Conclusions: Coagulopathy associated with Coivd-19 remains a real possibility as our knowledge continues to evolve and expand, this has large implications for obstetric anaesthetic practice given that the status quo is to default to neuroaxial blockade to avoid intubation, the presenting APH is likely secondary to the COVID driven coagulopathy despite mild symptoms. In addition to measurement of platelets, routine measurement of PT, APTTR and fibrinogen levels should be routinely considered in all pregnant women with Covid-19 per the ISTH guidance to help in differential diagnosis, guide admission to hospital/intensive care and need for obstetric intervention.