Thrombocytopenia In Pregnancy Flashcards
What is the prevalence of thrombocytopenia in pregnancy?
8 - 10 % of pregnancies
What are the main causes of thrombocytopenia in pregnancy?
75 % gestational thrombocytopenia
15- 20 % hypertensive disorders
3- 4 % immune process ( ITP)
1 - 2 % infections- malignancies- rare constitutional thrombocytopenia
What is the limit of plt count that doesn’t require further investigation?
100 × 10⁹
What are the main features of gestational thrombocytopenia?
Prevalence 8% of pregnancies
Plt counts typically 70 - 100
No association maternal bleeding
No past history outside pregnancy
Occurrence: 3rd trimester
Spontaneous resolution after delivery (perform plt - 6 w postnatally )
No fetal thrombocytopenia
May recur in subsequent pregnancy
When should anaesthetic consultation be done in a woman with gestational thrombocytopenia?
When plt < 80
( most units will not consider epidural with plt< 80 )
When to consider steroids in gestational thrombocytopenia?
When the count 50 - 70
When should cord sample be taken in a pregnancy complicated by gestational thrombocytopenia?
When plt < 80
To ensure that baby’s counts are normal &
*Avoid: fetal scalp electrodes and sampling/ high or mid cavity forceps
*Further neonatal samples on day 1 and day 4
What is the prevalence of ITP in pregnancy?
0.1 - 1 / 1000 of pregnancies
3 % of thrombocytopenia in pregnancy
How is ITP diagnosed in pregnancy?
1- exclusion: plt antibodies lack sensitivity & specificity
2- history
3- bone marrow test isn’t indicated
What are the interventional levels of plt in non hemorrhagic cases of ITP in pregnancy?
📌 antenatal, 👉 > 20
📌 vaginal D 👉 > 40
📌 operative or instrumental delivery 👉 > 50
📌 epidural 👉 > 80
What is the treatment choices in women with ITP to increase plt count before delivery?
❤ prednisolone: first line choice
Starting dose : 20 daily
Escalating to 60 if no or inadequate response is seen after 1 w
[ lower doses than non pregnant to minimize the risk of GDM / postpartum psychosis]
❤ IV immunoglobulin
❤ rarely: platelet transfusion
Or splenectomy
When should IV immunoglobulin be considered to increase the plt count before delivery?
- counts are very low
- the woman experiencing haemorrhage
- an adequate response to steroids
🚩 anti-D appears to have efficacy equal to IV immunoglobulin in Rh(-)
Women.
In women with ITP in pregnancy
What is the type of antibodies? What is the main worry about the neonate ?
IGg 👉 cross the placenta 👉fetal thrombocytopenia
📌Main worry is possible ICH ( intracranial haemorrhage) in the neonate. [ RARE]
What is the correlation between maternal thrombocytopenia ( ITP) and the fetal count?what is the effect of maternal treatment on fetal count?
No correlation
Maternal treatment with steroid or IV immunotherapy don’t have any effect on the fetal count.
What is the incidence of thrombocytopenia among neonates if the mother has ITP?
14 - 37 %
When is the neonatal thrombocytopenia more likely to happen?
1- sibling with thrombocytopenia
2- mother has had a splenectomy
3- her plt count < 50 during pregnancy
What is the role of diagnostic procedures in predicting neonatal thrombocytopenia?
- fetal scalp samples: don’t produce reliable counts / shouldn’t be taken
- percutaneous umbilical blood sampling: risk of fetal haemorrhage & fetal death 2% ( more than the risk of ICH = 1 %)
What is the optimum mode of delivery in women with ITP?
1- CS is not recommended
2- avoid FBS + FSE + high or mid cavity forceps
3- cord sample: to assess the neonatal plt 👉 normal : no further sampling
👉 low : capillary sample- further samples on day 1 - d4 .
4- IM vit K should be avoided if the count is unknown
What is the management in neonates with severe thrombocytopenia?
1- IV immunoglobulin
2- intracranial doppler US
3- platelets transfusion if if there is life threatening haemorrhage.
What are the main points in pre-pregnancy counseling for women with ITP ?
*ITP relapse or worsen in pregnancy
* treatment will carry maternal & fetal risks
* 1/3 will require treatment
* risk of peripartum haemorrhage is low
What is the occurrence rate of severe thrombocytopenia among women with preeclampsia?
< 5 % of women with preeclampsia
What are the symptoms and signs of TTP ?
- microangiopathic hemolytic anaemia
- thrombocytopenia
- neurological symptoms ( headache + coma)
- renal dysfunction
What is the main aetiology of TTP?
📌von willebrand factor cleaving protein ( ADAMTS 13) - deficiency
🚩 acquired: caused by autoantibodies
🚩 congenital: rarely.
What is the incidence of TTP in pregnancy?
1 / 25 000
What is the time of onset of TTP in pregnancy?
Variable ranging from 1st T 👉 several weeks postpartum.
* 55 % SECOND TRIMESTER
When the maternal mortality is higher in TTP?
Newly presenting cases
What is the management of TTP in pregnancy?
1- plasma exchange
2- fresh frozen plasma
3- high dose steroids
🔴 delivery doesn’t improve outcome
What is the role of platelets transfusion in the management of TTP ?
Contraindication
Known to precipitate central nervous symptoms
How to differentiate between HELLP & TTP clinically?
HELLP : central nervous & renal systems are usually unaffected
In contrast to TTP
What are the main viral infections that may cause thrombocytopenia?
HIV
CMV
Epstein barr
What is the optimum antenatal management for gestational thrombocytopenia?
1- consultant care
2- exclude pathological causes
3- monitor plt every 4 - 6 w
