how i treat thrombocytopenia in pregnancy
Women should also have the blood count repeated 1-3 months after delivery to assess whether spontaneous resolution of the thrombocytopenia has occurred. Maternal anesthesia must be based on safety of the mother. The urine dipstick revealed significant proteinuria (2+). American Society of Anesthesiologists Task Force on Obstetric Anesthesia. The peripheral blood film revealed a true thrombocytopenia with the presence of several large platelets, 10-20 red cell fragments per high power field, scattered spherocytes, and occasional nucleated red cells; polychromasia was increased. Assessment of changes in coagulation in parturients with preeclampsia using thromboelastography. Renal function tests were normal. Blood 2013; 121:38. Thrombocytopenia develops usually in the third trimester of pregnancy, and at this time the probability of intrauterine destruction of platelets in the fetus is high, due to the transfer of antibodies to the mother through the umbilical cord into the fetal blood flow. The first is the presence of isolated thrombocytopenia and the differential diagnosis between primary immune thrombocytopenia and gestational thrombocytopenia. Prednisone and aspirin in women with autoantibodies and unexplained recurrent fetal loss. In neonates with thrombocytopenia, the platelet counts is obtained daily because its nadir is frequently seen 2-5 days after birth. Prompt delivery is indicated for pregnancies ≥ 34 weeks of gestation, evidence of fetal distress (based on fetal heart rate monitoring and biophysical profile), or severe maternal disease (Figure 2). Low Platelets and Pregnancy. Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. However, in a few patients, the low platelet count may compromise the ability to deliver epidural anesthesia and general anesthesia represents a greater risk. 2013; 121(1):38-47 (ISSN: 1528-0020). A few noteworthy points are listed here. Intensive postpartum monitoring is necessary in women with HELLP because laboratory abnormalities frequently worsen 24-48 hours after delivery with peak rise in LDH and platelet nadir. Sun D, Shehata N, Ye XY, et al. Introduction. However, it may be associated with more severe etiologies in a few patients. Assessment and management of immune thrombocytopenia in pregnancy and in neonates. Treatment of thrombocytopenia in these patients must always be balanced with the risk of thrombosis. Thrombocytopenia, defined as a platelet count < 150 × 109/L, is second only to anemia as the most common hematologic abnormality encountered during pregnancy.1 Three large series involving together > 26 000 women suggest that its prevalence at the end of pregnancy is between 6.6% and 11.6%.2-4 However, counts < 100 × 109/L, which is the definition for thrombocytopenia adopted by an International Working Group,5 are observed in only 1% of pregnant women. 2001 Feb;123(2):80-90. doi: 10.1055/s-2001-12410. Atypical HUS is the most common form of HUS in pregnancy and has been associated with congenital defects of the alternative pathway of the complement system.68. On examination, the patient was pale, tachycardic, and had a few ecchymoses on her legs. Two fetal deaths were recorded, one of which was caused by hemorrhage. Harde M, Bhadade R, deSouza R, Jhingan M. Indian J Crit Care Med. CAPS indicates catastrophic antiphospholipid syndrome; +/−, rare or absent (0%-20% of cases); +, fairly common (20%-50% of cases); ++, common (50%-80% of cases); and +++, very common or constant feature (80%-100% of cases). This site needs JavaScript to work properly. Liver biopsy is deferred because of its inherent risk. How I treat thrombocytopenia in pregnancy. Although representing no threat in the majority of patients, thrombocytopenia … Suggested approach to the management of patients with HELLP syndrome. The presence of DIC is considered a contraindication to conservative treatment. Thrombocytopenia can result from a variety of physiologic or pathologic conditions, several of which are unique to pregnancy. Fetal and neonatal alloimmune thrombocytopenia (NAIT) is a blood disorder that affects pregnant women and their babies. Does gestational hypertension become pre-eclampsia? Approximately two thirds of patients have a … Author information: (1)Department of Hematology, Qilu Hospital, Shandong University, Jinan 250012, China. Our discussion includes the antenatal and perinatal management of both the mother and fetus. PMID: 32023725 [Indexed for MEDLINE] MeSH terms. Causes of thrombocytopenia may be specific complications of pregnancy or have no relationship to pregnancy per se, although some of them may occur with increased frequency during gestation (Table 1). Blood. In this review, we describe a systematic approach to the diagnosis and treatment of these disease entities using a case presentation format. 346(13):995-1008. . Severe thrombocytopenia, type 2B von Willebrand disease and pregnancy. Other than an occasional large form, platelets should appear normal. Thrombocytopenia, defined as a platelet count < 150 × 10 9 /L, is second only to anemia as the most common hematologic abnormality encountered during pregnancy. Clinical management guidelines for obstetrician-gynecologists. Alternatively, some experts also advise a course of intravenous immunoglobulin (IVIg), 1 g/kg in 1 or 2 divided doses, which may be useful both diagnostically and therapeutically.17. The count should be performed on a cord blood sample or, preferably, a peripheral blood sample. Arch Dis Child Fetal Neonatal Ed. The blood count shows normochromic, normocytic anemia with no or mild evidence of microangiopathic hemolysis, a white blood cell count that is higher than usually seen in pregnancy and, in many but not all cases, thrombocytopenia. Platelet counts < 50 × 109/L occur in ∼ 10% of newborns of mothers with ITP, whereas platelet counts < 20 × 109/L occur in 5% of cases.18 Intracranial hemorrhage has been reported in 0%-1.5%.18,31,32 There are no indirect ways of measuring the fetal platelet count, and the correlation between maternal and fetal platelet counts is poor.4,31 The best predictor of severe thrombocytopenia at birth is its occurrence in an older sibling,2,43,44 Maternal response to treatment does not automatically protect the newborn from the development of thrombocytopenia. The clinician's task is to determine not only the pathophysiologic nature of the thrombocytopenia, but also the risk it poses to both mother and fetus. Estimation of the risk of thrombocytopenia in the offspring of pregnant women with presumed immune thrombocytopenic purpura. Would you like email updates of new search results? The peripheral blood film showed thrombocytopenia with some giant platelets, several schistocytes (> 10 hpf), and polychromatic cells. There is still ongoing research to determine the reason for the lowering of platelet count in women with a normal pregnancy. Gernsheimer T; James AH; Stasi R. A mild thrombocytopenia is relatively frequent during pregnancy … Women with no bleeding manifestations and platelet counts > 30 × 109/L do not require any treatment until delivery is imminent. Cohen DL, Baglin TP. and high ammonia. The HELLP syndrome affects 10%-20% of women with severe preeclampsia, but 15%-20% of patients do not have antecedent hypertension or proteinuria.51 Criteria for the diagnosis of HELLP syndrome have been published by Sibai and include hemolysis (abnormal peripheral smear, LDH > 600 U/L, or bilirubin > 1.2 mg/dL), aspartate aminotransferase > 70 U/L, and a platelet count < 100 × 109/L.52 The Martin et al criteria are less stringent and include an LDH > 600 U/L, an aspartate aminotransferase > 70 U/L and a platelet count < 150 × 109/L.53 A partial form of the disease among women with severe preeclampsia has been described, in which only 1 or 2 of the 3 components of the syndrome are present.54 Approximately 70% of women with HELLP have evidence of the syndrome antepartum (the majority of cases are diagnosed at 28-36 weeks of gestation) and 30% develop it postpartum.55, Hemolysis has the typical features of microangiopathic hemolytic anemia, including the presence of red cell fragments (schistocytes), elevated serum bilirubin (> 1.2 mg/dL), low serum haptoglobin levels (≤ 25 mg/dL), and elevated LDH (≥ 600 IU/L) levels. What are the most probable etiologies of her thrombocytopenia? 2020 Aug 24;9(1):799. doi: 10.4102/ajlm.v9i1.799. Transfusion guidelines for neonates and older children. Bone marrow examination is rarely necessary to evaluate a thrombocytopenic pregnant patient and is not required to make the diagnosis of ITP. Although representing no threat in the majority of patients, thrombocytopenia may result from a range of pathologic conditions requiring closer monitoring and possible therapy. Intravenous anti-D as a treatment for immune thrombocytopenic purpura (ITP) during pregnancy. In most cases, thrombocytopenia was mild to moderate and the pregnancies were uneventful; however, 31% required intervention to increase the platelet count at some time during their pregnancy. Management of immune thrombocytopenic purpura in pregnancy. Her platelet count remained 50-60 × 109/L. How I treat thrombocytopenia in pregnancy. A 36-year-old woman, gravida 2 para 2 (G2P2), with a history of ITP since age 28 asks whether she can safely become pregnant again. Delivery is recommended for women who do not respond to plasma exchange.66 Renal failure may require supportive care with dialysis. Number 6, September 1999. A 38-year-old gravida 2 para 0 woman at 39 weeks' gestation presented to the obstetric unit after a tonic-clonic seizure witnessed by her husband. Thrombocytopenia may be the only initial manifestation of preeclampsia. Table 4 lists currently available therapeutic options in pregnant women with ITP. Treatment guideline for patients with persistent immune thrombocytopenia requiring treatment. A mild thrombocytopenia is relatively frequent during pregnancy and has generally no consequences for either the mother or the fetus. Blood 2017;130:2271–2277. Birth defects after maternal exposure to corticosteroids: prospective cohort study and meta-analysis of epidemiological studies. Contribution: T.G., A.H.J., and R.S. Thyroid testing and serum chemistries, including liver function, were unremarkable. 2019 Dec 14;40(12):977-979. doi: 10.3760/cma.j.issn.0253-2727.2019.12.001. Differentiating it from gestational thrombocytopenia may be problematic, if not impossible, in the absence of prepregnancy platelet counts or a previous history of ITP, as both entities are diagnoses of exclusion.