Abstract
Chronic ITP with thrombocytopenia presenting with Hemoperitoneum can be a life-threatening event. In the current case report 27 yrs old unmarried woman with history of Chronic ITP but discontinued treatment for four years presented to ER with Acute abdominal pain and hemorrhagic shock. Her hemoglobin was low-6.3g/dl, Platelets very low-2000/cu.mm, urine beta Hcg negative. On CT imaging free fluid detected in the peritoneal cavity with Rt adnexal lesion. After immediate resuscitation in ER, pt was shifted to theater for Laparoscopy. Hemoperitoneum due to rupture of corpus luteum cyst was found intraoperatively. Adequate fluid ,platelets and component therapy was life saving for this patient. This case report emphasizes the importance of patient compliance of treatment for Chronic ITP to avoid critical bleeding events with low platelet count.
Introduction
ITP is a hematological disease characterized by autoimmune mediated platelet destruction and reduced platelet production. Typically this disease manifests either acutely or in the Chronic form. ITP usually follows a relatively benign course and remains largely asymptomatic with symptoms occurring at very low platelet count. In young women corpus luteal rupture after ovulation is asymptomatic, but in the setting of Chronic ITP with very low Platelets of 2000 hemorrhage from corpus luteal rupture caused life-threatening Hemoperitoneum.
Case report
A 27-year-old unmarried woman with known history of Chronic ITP, defaulted treatment and didn’t take medications for four years. The patient was diagnosed with ITP in the year 2018 with platelet count of 7000.Initially started on Dexamethasone and Danazol. She was Refractory to the first line therapy agents. ANA screening was negative. With platelet count of 5000 she was started on Inj. Rituximab 100mg. Four doses was given and patient was started on triple drug therapy of Dexamethasone and Cyclosporin. Patient didn’t comply with treatment after 2019.Platelet count repeated in the year 2021 was 12,000/cu.mm.
She presented to ER with Acute lower abdominal pain and giddiness. On admission her vitals were BP 110/58 mmHg, PR 150/min, clinically she was anemic and diffuse tenderness present on abdominal examination. Her last menstrual period was ten days back. CT imaging of Abdomen and pelvis showed Hemoperitoneum with Right adnexal lesion of 5.5.5×4.1cm. Urine beta hcg negative, Hb 6.3g/dl and platelet count 2000/cu.mm. In the ER patient went for sudden hypotension ,she was immediately resuscitated with IVF,PRBC and shifted to theater with two RDP.SDP was arranged and patient taken up for Laparoscopy after informed and High risk consent from her parents.
Laparoscopy was proceeded with intraoperative finding of Hemoperitoneum of 1000ml with Clots 300gms,Rt Ovary was enlarged with hemorrhage and the hemorrhagic adexal mass distorted the Rt fallopian tube which was stretched over the lesion. Right salphingo oopherectomy was proceeded, saline wash given and DT kept. Intra operatively PRBC was transfused .In the immediate post operative period, 2 SDP,1PRBC and 4 RDP transfused.
The patient Hb improved and Platelet count was 24,000/cu.mm. Blood investigations like LFT, RFT, PT, INR, aPTT were normal. Inj Methyl prednisolone 500mg 3 doses were given and maintained on T.Eltrombopag 50mg OD and Inj. Romiplastim 25mcg.She made a good post operative recovery in the intensive care unit and was discharged on fifth post operative period.
Discussion
The etiology of ITP is classified according to primary and secondary causes. Primary ITP is a diagnosis of exclusion. While the pathogenesis in some cases remains idiopathic, it is largely accepted to be an immune mediated process and Platelet destruction. Secondary causes are preceding viral infection and medication e.g- NSAIDS, penicillin, quinine and malignant disorders such as leukemia. In ITP, an increased risk of spontaneous bleeding happens when Platelet levels fall below 20,000.It commonly presents with mucocutaneous manifestations such as bleeding from mucosa membranes and potential rash. Other symptoms may include gum bleeding is and menorrhagia with more severe features involving GI bleeding or intracerebral hemorrhage.
In a woman of childbearing age with presentation of sudden hypotension its important to rule out rupture of ectopic pregnancy. Case reports of Hemoperitoneum secondary to ruptured ovarian cyst due to low platelet count are documented. In Chronic ITP patient who defaulted treatment the normal physiological process of ovulation could be complicated by bleeding from the ruptured follicle and increase the risk of spontaneous Hemoperitoneum. The thin walled structure and highly vascular nature of corpus luteum renders it more prone to hemorrhage. While bleeding may be contained within the cyst, there is a possibility that it may spread into the peritoneal cavity.
Conclusion
Thus this case report describes rare presentation of spontaneous Hemoperitoneum secondary to ovulation in a patient with chronic ITP who defaulted treatment. Critical bleeding events like intraocular, intracerebral hemorrhage, or Hemoperitoneum with shock occurs in ITP with low platelet counts. This emphasizes the significance of the therapeutic agents in ITP and the multidisciplinary team approach of management of patients with ITP.
Dr. Anitha
Senior Consultant Obstetrician and Gynecologist
Kauvery Hospital Chennai