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Thrombocytopenia is a common finding in pregnancy. Establishing the diagnosis of immune thrombocytopenia (ITP) in
a pregnant patient is similar to doing so in a nonpregnant patient, except that the evaluation must specifically rule out
other disorders of pregnancy associated with low platelet counts that present different risks to the mother and fetus
and may require alternate distinct therapy. Many of the same treatment modalities are used to manage the pregnant
patient with ITP, but others have not been determined to be safe for the fetus, are limited to a particular gestational
period, or side effects may be more problematic during pregnancy. The therapeutic objective differs from that in
chronic ITP in the adult because many pregnant patients recover or improve spontaneously after delivery and therefore
maintenance of a safe platelet count, rather than prolonged remission, is the goal. Thrombocytopenia may the limit
choices of anesthesia, but does not guide mode of delivery, and the fetus is rarely severely affected at birth. Patients
should be advised that a history of ITP or ITP in a previous pregnancy is not a contraindication to future pregnancies
and that, with proper management and monitoring, positive outcomes can be expected in the majority of patients.
Thrombocytopenia is a very common finding in pregnancy, occurring in approximately 10% of women.1,2 Although most women
maintain a normal platelet count throughout gestation, the normal
range of platelet counts decreases, and it is not uncommon for the
platelet count to decrease as pregnancy progresses. Most low
platelet counts observed in the pregnant patient are due to normal
physiologic changes,3 whereas some disorders associated with
thrombocytopenia occur with higher frequency and some causes are
exclusive to pregnancy.4 When considering the diagnosis of immune thrombocytopenia (ITP) in pregnancy, all potential causes of
thrombocytopenia must be considered and ruled out in turn.
Gestational thrombocytopenia
Incidental or gestational thrombocytopenia is the most common
cause of pregnancy-associated thrombocytopenia, accounting for
65%-80% of cases.1,4 Increased blood volume, an increase in
platelet activation, and increased platelet clearance contribute to a
physiologic decrease in the platelet count.3 Platelet counts are
slightly lower in women with twin compared with singleton
pregnancies, possibly due to increased coagulation system activation in the placenta. These changes generally bring about only a
mild decrease in the platelet count, typically approximately 10%.5
The mean platelet count in pregnant women at term was found to be
213 000/L compared with 248 000/L in age-matched controls.1,6
Gestational thrombocytopenia tends to occur late, usually during the
third trimester,7 but it should be noted that thrombocytopenia that
appears during the last weeks of pregnancy can be the harbinger of
HELLP syndrome (hemolysis, elevated liver function tests, low
platelets) or acute fatty liver.8 Platelet counts 70 000-80 000/L
or occurring during the first or early in the second trimester suggest
an etiology other than gestational thrombocytopenia and require
further evaluation.9
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Gestational thrombocytopenia is not associated with adverse outcomes to the mother or fetus, and if the infant is thrombocytopenic,
other etiologies such as infection and neonatal alloimmune thrombocytopenia should be investigated.4 Thrombocytopenia in the mother
generally resolves quickly after delivery, usually within days and
always within weeks.
include preeclampsia, HELLP syndrome, acute fatty liver, disseminated intravascular coagulation, thrombotic thrombocytopenic purpura, and hemolytic uremic syndrome. The abnormal clinical and
laboratory findings that accompany these nutritional and BM
disorders are the basis for distinguishing them from ITP. Careful
review of the blood smear will help to exclude the thrombotic
microangiopathies associated with pregnancy (ie, HELLP syndrome, thrombotic thrombocytopenic purpura, and hemolytic uremic syndrome) by the absence of schistocytes. Normal coagulation
studies will be helpful in excluding acute fatty liver and disseminated intravascular coagulation.
Thrombocytopenia may be the primary manifestation of viral
infections such as HIV, viral hepatitis, EBV, and CMV. Thrombocytopenia is also a common adverse reaction from many drugs and
supplements. Women who receive low-molecular-weight or unfractionated heparin are at risk of heparin-induced thrombocytopenia
and should undergo testing, particularly in the presence of new or
worsening thrombosis.
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Management of delivery
ITP in the mother is not an indication for Caesarean section,34 and
the mode of delivery in a pregnant patient with ITP is based on
obstetric indications. Most neonatal hemorrhage occurs at
24-48 hours35,36 and is not related to trauma at the time of delivery.
Determination of the fetal platelet count by periumbilical blood
sampling37 or fetal scalp vein blood draws present a potential
hemorrhagic risk to the fetus and may inaccurately predict a low
platelet count.16 For this reason, fetal platelet count measurement is
not recommended. The best predictor of thrombocytopenia at birth
is its occurrence in an older sibling. In this case, Caesarean section
may be more prudent than vaginal delivery.
Maternal anesthesia must be based on safety of the mother. The risk
of spinal hematoma at lower platelet counts is unknown, but recent
recommendations are to withhold spinal anesthesia for women with
platelet counts below 75 000/L.38-40 Thromboelastograms have
been suggested to evaluate the entire hemostatic state of the
mother,41 but their usefulness is unclear. The bleeding time has also
been suggested as a mode of establishing the safety of the platelet
count,42 but most centers no longer offer this test and the experience
in using it to predict bleeding at delivery is limited. For patients who
have not required therapy during gestation but have platelet counts
below the threshold required for epidural anesthesia, short-term
corticosteroids (1-2 weeks) or IV Igs may help in preparing for the
procedure. Platelet transfusion is not appropriate to prepare the
mother for spinal anesthesia because posttransfusion increments
may be inadequate or short-lived and should be reserved to treat
bleeding only.
should be avoided unless it has been determined that the neonate has
a safe platelet count. The nadir platelet count frequently occurs 2-5
days after birth, so the mother needs to be made aware of signs of
bleeding and the baby should be checked early on by a pediatrician
if he/she has been discharged to home. The thrombocytopenia can
last weeks to months.50 A platelet count 50 000/L may be
treated with IV Ig (1 g/kg), which can be repeated every few weeks
as necessary to maintain a safe platelet count until the count
spontaneously recovers.
9.
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Conclusion
ITP occurs fairly commonly in otherwise uncomplicated, normal
pregnancies, but must be distinguished from more commonly
occurring incidental gestational thrombocytopenia. Other disorders
that may be associated with thrombocytopenia must be considered
and ruled out so that appropriate therapy can be instituted. The
diagnosis and management of ITP in pregnancy is similar to that in
the nonpregnant adult patient, but the risks to the developing fetus
must be taken into account when choosing treatment and the
maintenance of a safe platelet count, rather than prolonged remission, is the goal. Mode of delivery must be guided by obstetrical
indications. A history of ITP or ITP in a previous pregnancy is not a
contraindication to pregnancy, and the majority of patients deliver
nonthrombocytopenic or only mildly thrombocytopenic infants.
Disclosures
Conflict-of-interest disclosure: The author has received research
funding from Shionogi; has consulted for Glaxo-SmithKline, Clinical Options, Symphogen, Amgen, and Cangene; and has received
honoraria from Hemedicus, Laboratorios Raffo, and Amgen. Offlabel drug use: rituximab and azathioprine for ITP in pregnancy.
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Correspondence
Terry B. Gernsheimer, MD, Box 357710, University of Washington, Seattle, WA 98195; Phone: 206-292-6521; Fax: 206-233-3331;
e-mail: bldbuddy@u.washington.edu.
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