Thrombocytopenia+in+Pregnancy

This page has been edited {$pagerevisions} times. The last modification was made by user:{$revisioneditor} on {$revisiondate} Consultation available 24 hours per day from OB on-call at 925-370-5608 or via page/amion on-call schedule, via inbasket to OB dept member or by calling Perinatologist at 510-444-0790 during the day and 510-204-1572 after hours. Consultation appointments or transfer of care to more experienced prenatal clinician available at major clinics sites—see consultation guidelines for more information.

** Thrombocytopenia in Pregnancy ** Generally diagnosis is **__Immune Thrombocytopenic Purpura/ (ITP)__** or **__Gestational Thrombocytopenia__**. The treatment and monitoring of both is similar so differentiation between the two diagnoses is not essential. Of course, be sure to rule out/consider other potential diagnoses including AIDS related thrombocytopenia, Cirrhosis, Severe Preeclampsia/HELPP, and TTP (Thrombotic Thrombocytopenic Purpura). These can generally be ruled out by history, and exam/labs already performed as part of usual prenatal care.
 * __Diagnosis__**

The diagnosis is more likely ITP as opposed to Gestational Thrombocytopenia if
 * Platelet count low early in pregnancy or outside of pregnancy
 * More significant decrease in platelet count, especially if goes < 50,000
 * __Additional Tests__**
 * 1) If noted later in pregnancy evaluate urgently for **Preeclampsia and HELPP** (Blood Pressure, urine creat/pro ratio, creat, ALT, AST) and **TTP** (malaise, bruising, diarrhea, HTN, rapidly falling platelet count).
 * 2) Consider evaluation for liver disease if the history or exam is suggestive. Make sure HIV test has been performed.
 * 1) Consider evaluation for liver disease if the history or exam is suggestive. Make sure HIV test has been performed.

à If these rare but dangerous diagnoses are excluded make the diagnosis of **ITP** and/or **Gestational Thrombocytopenia --//Anti-platelet antibodies are not necessary or recommended//**

Treatment is instituted to prevent spontaneous bleeding during pregnancy. The goal is to keep the platelet count > 30,000 (note previously 50, 000 was the goal during pregnancy). Late in pregnancy, generally post 36 weeks, the goal is to increase the platelet count to > 80,000 so that regional anesthesia is safe and the patient has access to epidural and spinal anesthesia common at the time of delivery. Some anesthesiologists will be comfortable with a lower count in certain circumstances and all agree in ITP/gestational thrombocytopenia that > 80,000 is safe for regional anesthesia. Platelet counts are monitored on a 1-6 week interval depending on level and weeks of gestation. Usually checking CBCs with other periodic blood tests is adequate early in pregnancy. Late in pregnancy platelet counts are checked as often as every week depending on rate of change and proximity to the goal numbers.
 * __Monitoring__**

The usual treatment for low platelets is prednisone starting at 40-60mg daily and then slowly tapering after the platelet count has increased appropriately. If there also is a diagnosis of GDM/DM, an increase or addition of medication to control sugars may be necessary while she is on prednisone. If there is inadequate response to steroids or a critically low platelet count, consult with Heme/Onc **__and__** Obstetrics regarding the treatment, and timing of additional treatments. Sometimes IVIG, or other agents are necessary. IVIG is given in pregnancy on the Labor and Delivery Unit—to schedule call 925-370-5608. Please review delivery plan with an OB on-call, in advance of the delivery date, especially If there are other obstetric delivery issues, e.g. timing of elective cesarean, placenta previa, etc.. If the diagnoses is ITP or possibly ITP, the baby should have a cbc/platelet count checked after birth to evaluate for neonatal thrombocytopenia. This is almost always normal.
 * __Treatment__**
 * __Neonatal Evaluation__**

Note that a history of having a baby with low platelets in the past can be an indication of NAIT—Neonatal autoimmune idiopathic thrombocytopenia.--a condition where the mother has antiplatelet antibodies to an antigen not on her own platelets. Her own platelet count is normal. This has a high rate of recurrence and is very dangerous to the current baby. If you find a history of a prior baby with low platelets (often these children have sequelae from a bleed in the intrapartum or neonatal time period) consult with OB/Perinatology immediately.