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Thrombocytopenia during pregnancy
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Thrombocytopenia
During pregnancy Prof Aboubakr Elnashar
Benha university Hospital, Egypt
Aboubakr Elnashar
Causes 1. Spurious result (reduced platelets on automated
Coulter counter {platelet clumping or misreading
of large immature platelets as red cells}
2. Gestational thrombocytopenia
3. Immune thrombocytopenic purpura (ITP)
4. Pre-eclampsia and Haemolysis, Elevated Liver
enzymes and Low Platelets (HELLP) syndrome
5. Disseminated intravascular coagulation (DIC)
Aboubakr Elnashar
6. Haemolytic uraemic syndrome (HUS) /thrombotic
thrombocytopenic purpura (TTP)
7. Sepsis
8. Human immunodeficiency virus (HIV), drugs and
infections (e.g. malaria)
9. Systemic lupus erythematosus (SLE) and
antiphospholipid syndrome (APS)
10. Bone marrow suppression.
Aboubakr Elnashar
Incidence 5-10%: of pregnant women
Gestational' thrombocytopenia:75%
Chronic ITP:
1-2/10,000 pregnancies.
usually affects young Women
female to male ratio = 3:1
Aboubakr Elnashar
AIloimmune thrombocytopenia
fetal disorder
{fetomaternal incompatibility for platelet antigens
(similar to Rhesus haemolytic disease of the
newborn)}
No maternal symptoms and the mother is not
thrombocytopenic.
The condition develops in utero, affects all children
including the firstborn, but is usually (except in the
case of Subsequent siblings) diagnosed after birth.
Incidence: 1 in 2000
causes 10% of all cases of neonatal
thrombocytopenia.
Aboubakr Elnashar
Clinical features Gestational thrombocytopenia:
Benign condition
platelet count <100 x 109/L: no adverse
consequences for mother or baby.
Thrombocytopenia in the first half of pregnancy:
less likely to be gestational: possible diagnosis of
ITP.
Aboubakr Elnashar
ITP
Isolated thrombocytopenia without any associated
haematological abnormality.
No splenomegaly or lymphadenopathy.
Haemorrhage: unlikely with platelet counts >50 x
109/L
Spontaneous haemorrhage without surgery:
unlikely with counts >20 x 109/L.
±skin bruising or gum bleeding
severe haemorrhage: rare.
Aboubakr Elnashar
Pathogenesis Gestational thrombocytopenia
Normal pregnancy: Platelet count fall progressively
5% to 10%: thrombocytopenic levels (50-150 x
109/L) by term.
ITP
Autoantibodies against platelet surface antigens:
peripheral platelet destruction by the
reticuloendothelial system, particularly the spleen.
Aboubakr Elnashar
Diagnosis ITP
By exclusion: other causes (infection and PET)
Bone marrow:
normal or megakaryocytic
not necessary in pregnancy in cases of isolated
thrombocytopenia unless it is severe (platelet count
<30 x 109/L)
Antiplatelet antibody:
not readily available
not helpful {absence of antiplatelet antibodies does
not exclude the diagnosis of ITP.}
Aboubakr Elnashar
Effect of pregnancy on ITP
Pregnancy does not affect the course of ITP
Anxieties arise around the time of delivery
{possible bleeding associated with
vaginal and abdominal delivery and
regional anaesthesia and analgesia}.
Aboubakr Elnashar
Effect of ITP on pregnancy Capillary bleeding and purpura:
unlikely with a platelet count of >50 x 109/L
Spontaneous mucous membrane bleeding:
not a risk with platelet counts >20 x 109/L.
Aboubakr Elnashar
Antiplatelet IgG can cross the placenta: fetal
thrombocytopenia.
Prediction of the fetal platelet count from
maternal platelet count
antibody level or
splenectomy status: not possible
Fetal platelet counts <50 x 109/L:
5% to 10%
10-15% in:
ITP before pregnancy
symptomatic ITP in the index pregnancy.
Aboubakr Elnashar
Antenatal or neonatal intracranial haemorrhage
0% to 1.5%
lowest in the absence of
maternal symptoms or a history of ITP prior to the
index pregnancy.
One of the best predictors of severe neonatal
thrombocytopenia is a previously affected child
Incidence of serious haemorrhage in the fetus and
neonate: low.
Aboubakr Elnashar
Management Gestational thrombocytopenia
Benign condition: no intervention.
Aboubakr Elnashar
ITP
Maternal considerations
Exclude associated conditions:
SLE (ANA, double stranded DNA, smith) or
APS.
The platelet count should be monitored
monthly and then more frequently in 3rd T: therapy
can be instituted if required prior to delivery.
Treatment is only required in 1st and 3rd T:
The woman is symptomatic with bleeding
The platelet count is <20 x 109/L
The count needs to be increased prior to a
procedure such as chorionic villous sampling (CVS)
Aboubakr Elnashar
Counts:
<50 x 109/L (even in the absence of bleeding):
prophylactic treatment prior to delivery.
50 to 80 x 109 /L
may warrant treatment prior to delivery {facilitate
safe regional analgesia}.
Aboubakr Elnashar
CS:
only required for obstetric indications
Epidural and spinal anaesthesia:
safe with stable counts >75 to 80 x 109/L.
Bleeding time does not predict haemorrhage and is
not indicated‘
Aboubakr Elnashar
Corticosteroids:
first-line therapy
Prednisolone dose:
Non pregnant:
(60-80 mg/d, 1 mg/kg/d)
Pregnancy:
lower doses (20-30 mg/d): safe and effective.
then dose may be weaned to the lowest that will
maintain a satisfactory (>50 x 109/L) maternal
platelet count
Aboubakr Elnashar
IV immunoglobulin (IVIg)
Indication:
resistant cases
women likely to require prolonged therapy
women requiring a high maintenance dose of
prednisolone or
who are intolerant of prednisolone.
Mechanism:
delaying clearance of IgG-coated platelets from the
maternal circulation.
Aboubakr Elnashar
Response:
more rapid (24-48 h) than with steroids: useful if a
rapid response is required.
lasts for two to three weeks
Disadvantages:
Expensive
seldom produces long-term remission.
Dose:
0.4 g/kg/ day for five days or 1 g/kg over eight hours,
repeated two days later if there is an inadequate
response.
Aboubakr Elnashar
Anti-D immunoglobulin
Indication:
non-splenectomised rhesus-positive women.
Mechanism:
creating a decoy to competitively inhibit the
destruction of antibody-coated platelets: raise platlet
count.
Doses: IV bolus
50 to 70 µg/kg.
Safe and effective in 2nd and 3rd T.
Monitor baby
neonatal jaundice
anaemia, and
direct antiglobulin test positivity after delivery. Aboubakr Elnashar
Splenectomy
should be avoided in pregnancy if possible
May be necessary in extreme cases.
Performed in the second trimester and can at this
stage be performed laparoscopically.
Women with ITP who have previously been treated
with splenectomy should continue penicillin
prophylaxis throughout pregnancy.
Aboubakr Elnashar
Other options for women who fail to respond to
oral prednisolone and IVIg
i.v. methylprednisolone
azathioprine or ciclosporin.
danazol and vincristine: Although not recommend
have been successfully used for severe resistant
cases in pregnancy.
Aboubakr Elnashar
Platelet transfusions
last resort for bleeding or
prior to surgery
increase antibody titres
do not result in a sustained increase in platelet
counts.
Aboubakr Elnashar
Fetal considerations
No place for serial fetal blood samples earlier in
gestation {Transfer of IgG increases at the end of
pregnancy and the baby is not at risk of bleeding
before labour and delivery}
The risk of fetal blood sampling via cordocentesis
(cord spasm, haemorrhage from the cord puncture
site) is similar (or even higher in thrombocytopenic
fetuses) to the risk of intracerebral haemorrhage
(ICH).
Aboubakr Elnashar
CS:
only indicated for obstetric reasons.
{no conclusive evidence that SC reduces the
incidence of ICH, or that it is less traumatic for the
fetus than vaginal delivery}
Aboubakr Elnashar
Neonatal consideration
Cord platelet count is determined immediately
after delivery
Neonatal platelet count:
only reaches a nadir after two to five days in affected
infants {splenic circulation is established}: most
hemorrhagic events in neonates occur 24-48h after
delivery at the nadir of the platelet count: monitoring
is necessary over this time.
IVIg
the recommended treatment for neonates with
bleeding or severe thrombocytopenia; this may be
given prophylactically if the platelet count of the cord
blood is low «20 x 109 /L). Aboubakr Elnashar
Conclusion
ITP
The diagnosis of ITP is one of exclusion and
should only be made once other causes of
thrombocytopenia have been excluded.
Bleeding is unlikely if the platelet count is >50 x
109/L.
The risk of serious thrombocytopenia and
haemorrhage in the neonate from transplacental
passage of antiplatelet IgG is low.
CS is only required for obstetric indications and
epidural and spinal anaesthesiajanalgesia are safe
with stable counts >75 to 80 x 109/L.
Treatment, if required, should be with
corticosteroids or IVIg). Aboubakr Elnashar
History and Physical
Normal
Repeat platlet count
normal
- Assume lab error
- No further workup
1st T platlet count low
Assume ITP
Counsel: risks of neonatal thrombocytopenia
Inform anesthesia and pediatric staff
Ensure no spontaneous bleeding
Ensure platelets >50K at delivery
1st T platlet count
normal
Assume gestational thrombocytopenia: no further work up
Abnormal
Aboubakr Elnashar
Abnormal
History of medications
-Alternative medication
- Counsel maternal an fetal risk
Evidence of systemic disease
Management depend on type of illness e.g. self limiting viral illness or ch rheumatologic dis
Elevated BP with normal BP in 1st T
Assume hypertensive disorder of pregnancy
Management depend on gest age and s and s of maternal and f disease
Aboubakr Elnashar
Thanks
Aboubakr Elnashar