How does low platelets affect pregnancy

Moderate to severe bleeding with thrombocytopenia and no findings of microangiopathic hemolytic anemia can be treated with platelet transfusions as evaluation for underlying etiology of thrombocytopenia continues. Bleeding is not a feature of gestational thrombocytopenia, as the platelet count does not drop low enough to result in bleeding.

Even in patients who do not have clinically significant bleeding, the platelet count serves as a guide for urgency of institution of therapy.

The platelet count will continue to rise over the next few days. The question of whether to admit the pregnant patient with an extremely low platelet count to the hospital for treatment can arise.

In a reliable patient with a known diagnosis of ITP, with no clinical signs or symptoms of bleeding, a normally progressing pregnancy, and ability to return the following day for evaluation and CBC, admission for IV IgG is not necessary. If however, there is any doubt about the diagnosis, or the ability of the patient to return if bleeding develops, or if labor is imminent, admission is warranted. IV IgG is a treatment that only temporarily raises the platelet count. The duration of response to one dose of IV IgG is variable, lasting from 1 to 6 weeks.

Further treatment should be planned, as described below. Cesarean section C-section can be performed if necessary, and epidural or spinal anesthesia used if desired or necessary. These treatment plans vary somewhat depending on whether labor and delivery will occur spontaneously or will be a scheduled induction of labor or elective C-section.

The threshold platelet count for treatment is variable. The rapidity with which the platelet count falls is often a more significant factor in determining need for therapy in ITP than the actual number. Platelet counts can be checked once a month in early pregnancy as long as they are stable and as long as the patient is aware that she should have a platelet count with the onset of any new bleeding epistaxis, gingival bleeding, bruising. As pregnancy progresses, the platelet count should be obtained every 2 weeks starting in the third trimester, and then once a week after 36 weeks.

It takes longer to see an increase in the platelet count with corticosteroids than with IV IgG, with an increase in platelet count often not observed until after days of treatment. Early in pregnancy during organogenesis there is concern for an association between glucocorticoids and oral clefting in animals; in humans the relationship is not clear but cannot be excluded.

Corticosteroids are also associated with gestational diabetes and hypertension, and less commonly premature rupture of membranes and placental abruption. Both prednisone and dexamethasone can be used to treat ITP. Recent data suggest equivalent efficacy in the short term. The standard dosing regimen for dexamethasone is 40 mg po qd for 4 days, repeated every 14 days for 4 cycles.

Many hematologists will start all patients on 60 mg of prednisone po qd regardless of weight. In pregnant women early in gestation the starting dose of prednisone can be lower, e.

If there is no response after 4 weeks, steroids should be tapered. Most obstetricians prefer prednisone, as fewer metabolites cross the placenta compared to dexamethasone; however, the actual difference may be not be significant because of differences in dose and schedule of administration.

Patients with presumed gestational thrombocytopenia do not require treatment, but platelet counts need to be followed over time in case the diagnosis is, in fact, ITP. Since gestational thrombocytopenia usually presents in late pregnancy, when visits to the obstetrician usually occur every 2 weeks, the platelet count can be checked at the same time.

If there is no significant change over this time period, then concern for further decrease at time of labor and delivery is lessened. In this case the next step is to use the combination of steroids and IV IgG, especially in the third trimester.

Often high dose IV methylprednisolone mg can be used to achieve an increase in platelet count. Splenectomy is safe for both mother and fetus prior to 26 weeks gestation. After that time the size of the pregnant uterus makes it technically difficult. There were some early reports of anti-RhD causing acute renal failure due to hemoglobinemia or hemaglobinuria in 0. Patients must be Rhesus Rh positive in order for therapy to be effective.

Newborns should be evaluated for jaundice. Although complications are rare, it is infrequently used in pregnant patients who may already be anemic. The use of rituximab, an anti-CD 20 monoclonal antibody, in pregnancy has been limited to patients with lymphoma during the second and third trimesters. There is one case report of the use of rituximab to treat ITP in the third trimester of pregnancy.

In this case, the lymphocyte count of the infant was low at birth, but normalized by 6 months of age. Other case reports also note no obvious long-term adverse effects in lymphocyte populations, hematopoiesis or immunity in infants born to mothers treated with rituximab during pregnancy; however, data are limited and routine use in pregnancy cannot be recommended.

Thrombopoietin TPO mimetics bind to the thrombopoietin receptor and result in increased platelet production by initiating signal transduction through the JAK 2 tyrosine kinase pathway. No data are available for use in pregnancy; however, data will be collected from those patients who become pregnant while on TPO mimetics. The effects of TPO mimetics on the developing fetal bone marrow are unknown.

There is also an increased risk of thrombosis in non-pregnant patients treated with TPO mimetics that could be potentially higher in the pregnant patient given the hypercoagulable state of pregnancy. Azathioprine, cyclophosphamide, cyclosporine, vincristine and other cytotoxic or immunosuppressive agents have been used to treat ITP after the first trimester when organogenesis is complete. Although many report the safe use of these agents in pregnancy after the first trimester, use in pregnancy is generally avoided if possible.

For severe refractory cases of ITP, use of other treatments including Campath, autologous and even allogeneic stem cell transplant have been reported; these can be considered for use after delivery.

Patients with chronic liver disease and thrombocytopenia from portal hypertension and resultant splenic sequestration benefit from platelet transfusions. Other ancillary therapies, such as lV IgG or steroids, have no impact on the platelet count in this situation. Gestational thrombocytopenia will resolve after delivery, with no sequelae. There is no associated risk of thrombocytopenia in the fetus.

In ITP, the platelet count can decrease to extremely low levels requiring treatment during pregnancy. Patients will require close monitoring, especially in the third trimester as delivery approaches. Collaboration and coordination between hematologist, obstetrician, and anethesiologist is required to ensure safe delivery. ITP can resolve after delivery but may persist, however after delivery the therapeutic options are greater. The overall prognosis is good for patients with ITP, with excellent response to therapy.

In patients with ITP, there is anxiety about neonatal thrombocytopenia and subsequent hemorrhage, especially intracranial hemorrhage ICH , due to birth trauma at delivery.

The actual risks for bleeding in the neonate are low. Many studies of the platelet count in the fetus have found that the sampling methods, such as percutaneous umbilical cord blood sampling or fetal scalp blood sampling, are technically difficult, can give erroneous results, and have associated fetal bleeding risks that are equal to or greater than the risk of ICH. The risk of thrombocytopenia in the baby is low. Platelet counts in the newborn can be normal, but must be checked in the first few days after birth because the platelet count can rapidly decline due to circulating maternal antiplatelet antibodies nadir up to 5 days after birth.

Thrombocytopenia due to maternal ITP can persist in the newborn for 4 to 6 weeks after birth. The only predictor of thrombocytopenia in the newborn is a prior history of thrombocytopenia at birth in an older sibling.

Maternal platelet count, history of prior treatment including splenectomy, and other factors have been found not to correlate with thrombocytopenia in the newborn. Current guidelines suggest that vaginal delivery is safe for the infant. Maternal thrombocytopenia does not mandate C-section to decrease risk of ICH in the infant.

Secondary ITP due to other autoimmune or viral processes has a prognosis directly related to the underlying disorder. Gestational thrombocytopenia and ITP can be difficult to separate until after pregnancy. The main concern for women with ITP is the risk of neonatal thrombocytopenia and intercranial hemorrhage.

The correlation between maternal and neonatal platelet count is poor but some studies have shown that the relative risk of neonatal thrombocytopenia increases with decreased maternal platelet counts. The best predictor of a low platelet count at birth is an older sibling with thrombocytopenia at birth.

Maternal response to treatment does not automatically protect the neonate from development of thrombocytopenia.

A neonatal platelet count should be obtained at delivery and intermuscular injection of vitamin K should be deferred until platelet count is known. The risk of intracranial hemorrhage is up to1. Most neonatal hemorrhagic events occur 24 to 48 hours postdelivery when the platelet count is at its lowest point.

If the platelet count is normal, there is no need for repeat counts. In neonates with low platelet counts, transcranial ultrasound is recommended. Risk of IUGR, prematurity and fetal death is significant for the fetus due to extensive placental ischemia. Early plasma exchange may be helpful in reducing this risk.

Gestational thrombocytopenia—resolves spontaneously within a maximum of 1 to 2 months in all cases. There is a risk of recurrence in future pregnancies. ITP — up to one third of women require treatment in subsequent pregnancies. ITP may worsen or relapse in subsequent pregnancies, but it is hard to predict in whom this will occur. Prophylactic plasma exchange therapy may significantly reduce the risk of recurrence.

Due to the rarity of the condition, precise figures are difficult to verify. Burrows, R, Kelton, JG. N Engl J Med. A landmark cross sectional study of over 5, mother and infant pairs, describing the relationship of fetal thrombocytopenia to maternal thrombocyotpenia, outlining the rarity of severe fetal thrombocytopenia, and describing its relationship to mothers with antiplatelet alloantibodies.

Am J Perinatalol. A retrospective study which used a large data source with almost 12, mother-infant pairs to estimate the likelihood of a low neonatal platelet count with a predelivery maternal platelet count. Among Its strengths are the large patient numbers. Gernsheimer, TB. An excellent, comprehensive review of the investigation and management of thrombocytopenia in pregnancy.

Myers, B. Br J Haematol. Another excellent, evidenced-based guideline for the diagnosis and management of thrombocytopenia in pregnancy, with helpful algorithms and tables. An international consensus statement on primary immune thrombocytopenia in the general population, with an in-depth section on pregnancy. All rights reserved. No sponsor or advertiser has participated in, approved or paid for the content provided by Decision Support in Medicine LLC.

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Thrombocytopenia in pregnancy 1. Jump to Section Thrombocytopenia in pregnancy 1. What every clinician should know 2. Complications Maternal Risks Fetal risks 5. This doesn't affect how well the platelets work, though.

In pregnancy, this process is speeded up. The result is that you have fewer, but younger and larger platelets in your blood. Enter your due date or child's birthday dd 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 mm Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec yyyy Trying to conceive? We use your information to send you emails, product samples, and promotions on this website and other properties.

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