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Obstetrics > Thrombocytopenia in pregnancy > Flashcards

Thrombocytopenia in pregnancy Flashcards

1
Q

what are the causes of thrombocytopenia in pregnancy?

A 
Pregnancy related:
- PET
- HELLP
- gestational thrombocytopenia
- DIC
Non pregnancy related
Immune:
- ITP
- TTP/HUS/aHUS
- SLE
Non immune:
- infection (viral, H.Pylori)
- B12 deficiency
- Drug related
- congenital thrombocytopenia
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2
Q

What are the 3 most common causes of thrombocytopenia in pregnancy?

A
  • gestational (75%)
  • Hypertensive disorder (PET, HELLP)
  • ITP (4% of cases overall but most common if thrombocytopenia presents in 1st and 2nd trimester)
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3
Q

what is the history you would take for a patient with thrombocytopenia?

A
  • h/o bleeding or thrombosis
  • family h/o bleeding disorders
  • h/o bleeding - menorrhagia, gums bleeding
  • h/o HTN disorder or PET in previous pregnancies
  • h/o platelet disorder or neonatal thrombocytopenia
  • h/o other autoimmune conditions
  • drugs
  • diet (B12 def)
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4
Q

What is the examination you should do for someone with thrombocytopenia

A
  • review of mucosa and skin
  • review of petechia
  • splenomegaly
  • bruising
  • lymphadenopathy
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5
Q

what investigations should you arrange for someone with thrombocytopenia undifferentiated?

A
  • repeat platelets - may be artifact/mistake
  • blood film review by haematologist
  • U&E&C
  • LFT
  • Coags
  • HIV
  • h pylori
  • APS screening - beta glycoprotein, lupus anticoagulant, anticardiolipin
  • haemolysis screen - LDH, haptoglobin, reticulocytes
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6
Q

what labour considerations do you need to make for a woman with thrombocytopenia

A
  • centre with access to blood bank
  • if aiming for vaginal delivery platelets need to be >50
  • if aiming for regional anaesthetic platelets need to >70
  • avoid fetal scalp electrodes
  • avoid instrumental delivery
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7
Q

what are the limitations around post partum VTE prophylaxis in patients with thrombocytopenia?

A
  • as long as platetets are >50 aspirin and clexane are okay
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8
Q

What is ITP?

A
  • auto-antibodies directed against glycoproteins on the surface of platelets
  • leads to increased platelet destruction
  • the majority of auto-antibodies are IgG and therefore cross the placenta - need to consider fetal thrombocytopenia (managing mode of delivery)
  • may be associated with other auto-immune phenomenon
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9
Q

What are the features of a thrombocytopenia associated with acute fatty liver of pregnancy?

A
  • occurs in 3rd trimester
  • <1% of cases
  • prolonged PT and APTT
  • low fibrinogen
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10
Q

What are the 4 pregnancy associated causes of DIC?

A
  • placental abruption
  • amniotic fluid embolism
  • septic abortion
  • RPOC
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11
Q

what does TMA mean and how does it fit into the differential for thrombocytopenia in pregnancy?

A

thrombotic microangiopathy
refers to the group of typical HUS, atypical HUS and TTP
they have different mechanisms but all lead to thrombocytopenia and may all present for first time in prengancy

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12
Q

what is the pathophysiology of thrombocytopenia in Typical HUS?

A
  • toxin causes endothelial injury, platelet aggregation and red cell shearing
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13
Q

what is the pathophysiology of thrombocytopenia in atypical HUS?

A
  • complement activation leading to endothelial damage

- RBC shearing and thrombocytopenia

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14
Q

what is the pathophysiology of thrombocytopenia in TTP?

A

deficiency of a protein called Adams Ts13
cannot degrade vWB and platelet fibrils
can be acquired or congenital
acquired secondary to malignancy or infection
often presents itself in pregnancy (2nd hit hypothesis)

10-20% chance can get recurrence in 2nd pregnancy

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15
Q

treatment of typical HUS

A
  • support them through infection driven process
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16
Q

treatment of atypical HUS

A
  • can give a immunological drug

- stops C5 deposition

17
Q

Treatment of TTP

A
  • get rid of antibody

- steroids and plasma exchange to filter out antibody

18
Q

in a pregnant women with ITP and platelets >20 what do you recommend?

A
  • if not imminently delivering just continue to monitor
  • reassure that risk of bleeding is actually surprisingly low with platelets >20
  • platelet size are big and there is a hypothesis that the platelets may function better (explaining lack of bleeding)
19
Q

in a woman with platelets <20 with ITP how would you manage?

A
  • give steroids
    If bleeding as well:
  • platelet transfusion (these will be attacked by antibodies so may not last long but better than nothing)
  • IVIG
  • consider high dose prednisone (from 20 to 50mg daily)
20
Q

In patients with ITP, platelets <20 and life threatening bleeding what are the management options?

A
  • platelet transfusion
  • IVIG
  • High dose steroid
21
Q

If you are treating a woman with steroids for ITP what other considerations do you need to make in pregnancy and labour?

A
  • T2DM
  • BSL may go off
  • insomnia common side effect
  • mood lability
  • if on >5mg prednisone for >3 weeks this can cause adrenal insufficiency therefore at CS recommend 100mg IV hydrocortisone then 50mg IV 6 hours postpartum, if vaginal delivery consider 50mg IV hydrocortisone 6 hourly in active labour and until 6 hrs postpartum
22
Q

what neonatal considerations do you have to make for a women with ITP?

A

10% of neonates affected have platelets <50
(5% <20, 5% 20-50)
check cord blood platelet count at time of delivery
if low check daily (nadir day 2-5 postpartum)
if normal no further testing requiredL

22
Q

what neonatal considerations do you have to make for a women with ITP?

A

10% of neonates affected have platelets <50
(5% <20, 5% 20-50)
check cord blood platelet count at time of delivery
if low check daily (nadir day 2-5 postpartum)
if normal no further testing required

23
Q

List 3 risk factors for neonatal thrombocytopenia

A
  • previous sibling with thrombocytopenia
  • mother has undergone splenectomy
  • maternal ITP

Note maternal treatment of ITP does not protect neonate necessarily

Obstetrics (28 decks)

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