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thrombocytopenia
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Thrombocytopenia in Pregnancy
Thikra Aldwiala
R1 OB \ GYN residint
when to say throbcytopnia in pegnancy ?
what are the most common causes of thrompocytopenia in pregnancy ?
what are the risks on mother & baby ?
ACOG recommendations for practice .
when to say throbcytopnia in pegnancy ?
what are the most common causes of thrompocytopenia in pregnancy ?
what are the risks on mother & baby ?
ACOG recommendations for practice .
Definition
Definition
Thrombocytopenia can be defined as platelet count less than 150,000/μL .
Gestational thrombocytopenia
Preeclampsia
Immune thrombocytopenic purpura
Classification
Classification
Mild thrombocytopenia is 100,000-150,000/μL.
Moderate thrombocytopenia is 50,000-100,000/μL.
Sever thrombocytopenia is < 50,000/μL.
* Pregnant with a platelet count of less than 10,000 will has a clinically significant bleeding complications .
Manifistation
Manifistation
- By history :
- Current or previous bleeding problems
- Family history of bleeding
- Past obstetrical history
- Transfusion history
- By Examination :
- Petechiae, ecchymoses, and nose and gum bleeding .
- Rare : Hematuria, gastrointestinal bleeding , intracranial bleeding
Etiologic Classification
Etiologic Classification
Decreased platelet production
Increased platelet destruction
Splenic sequestration
Nonimmunologic-related thrombocytopenia
immunologic-related thrombocytopenia
Drug-induced
Aplastic anemia
Infection
Portal hypertension
Liver disease
ITP
SLE
Antiphosphlopid syndrome
Preeclampsia/ eclampsia
HELLP syndrome
TTP
Heparin-induced thrombocytopenia
Gestational Thrombocytopenia
Gestational thrombocytopenia, also called incidental thrombocytopenia of pregnancy and affects 8 % of pregnant women and accounts for more than 70% of cases of thrombocytopenia in pregnancy.
Criteria of Gastational Thrombocytopenia
- First, thrombocytopenia is relatively mild remaining more than 70,000 .
- Second, women with gestational thrombocytopenia are asymptomatic with no history of bleeding.
- Third, women have no history of thrombocytopenia outside of pregnancy.
- Fourth, platelet counts usually return to normal within 2–12 weeks after delivery .
Criteria of Gastational Thrombocytopenia
- First, thrombocytopenia is relatively mild remaining more than 70,000 .
- Second, women with gestational thrombocytopenia are asymptomatic with no history of bleeding.
- Third, women have no history of thrombocytopenia outside of pregnancy.
- Fourth, platelet counts usually return to normal within 2–12 weeks after delivery .
Risk and Complications
the incidence of fetal ...
Risk and Complications
the incidence of fetal or neonatal thrombocytopenia in the setting of gestational thrombocytopenia is low , it is determined by cord blood platelet counts in women with gestational thrombocytopenia, has been reported to range from 0.1% to 1.7% . Thus, women with gestational thrombocytopenia are not at risk of maternal or fetal hemorrhage or bleeding complications.
appropriate obstetric management for gestation...
appropriate obstetric management for gestational thrombocytopenia
- Interventions such as cesarean delivery and the determination of the fetal platelet count are not indicated in patients with this condition.
- Women with gestational thrombocytopenia do not require any additional testing or specialized care, except follow-up platelet counts.
- Most of the patients diagnosed at the time the of labor. However, if the diagnosis is made during the antepartum period, platelet count be checked weekly starting as early as 34 weeks of gestation .
- After childbirth, the platelet count should be repeated 1–3 months postpartum to determine if resolution of the thrombocytopenia has occurred.
Preeclampsia/Eclampsia
- Preeclampsia is accounts 21% of cases of maternal thrombocytopenia.
- Thrombocytopenia is usually moderate & rarely to be less than 20,000. It is considered a sign of worsening disease and is an indication for delivery .
Clinical Manifistation
Clinical Manifistation
The most severe spectrum of preeclampsia is established when the vascular endothelial damage produces microangiopathic hemolytic anemia, elevating liver enzymes along with thrombocytopenia and establishing aHELLP syndrome .
Risks and Complications
Risks and Complications
The perinatal mortality rate is 11% , may occur from placental abruption, asphyxia, and extreme prematurity.
Term babies are not at risk for thrombocytopenia , risk increase with prematurity & growth restrictions .
Major hemorrhage is infrequent in patients with preeclampsia but minor bleeding such as operative site oozing during cesarean delivery is common.
Management and Recommendations
Delivery is the ultimate cure.
Magnesium sulfate (MgSO4) should be administered intravenously to prevent seizures and for neuroprotection between 24 to 32 weeks.
HELLP syndrome with thrombocytopenia does not by itself require a cesarean delivery, although cesarean delivery may be acceptable prior to 32 weeks' gestation with an unfavorable cervix due to an anticipated long induction time in a clinically deteriorating gravida.
Maintain platelet counts >20,000/μL for vaginal delivery and 40,000 to 50,000/μL for cesarean delivery .
Thrombocytopenia with immune basis
Thrombocytopenia with immune basis
- Can be classified as 2 disorders :
- Neonatal alloimmune thrombocytopenia .
- Maternal immune thrombocytopenia .
Neonatal Alloimmune Thrombocytopenia
Neonatal Alloimmune Thrombocytopenia
It is a maternal alloimmunization to fetal platlets antigens , affect 1 in 1000 -10000 live birth & can occur during the first pregnancy .
- it has no effect on the mother .
- it has a risk of profound thrombocytopenia on the baby or fetal or neonatal intercranial hemorrhage .
- it has a high recurrence rate in further pregnancies .
Fetal intercranial hemorrhage
Fetal intercranial hemorrhage
porencephalic cyst
obstructive hydrocephalus
can be discovered in utero by ultrasound ..
ITP ..
ITP ..
- It is affecting 1 in 1000 - 10000 pregnancies .
ACOG criteria for diagnisis :
- First , persistent thrombocytopenia less than 100000 with or without megathrombo cyte in periphral smear .
- Second , normal or increse number of megakaryocytes in bone marrow .
- Third , exclusion of other systemic codition associated with thrombocytopenia .
- Forth , absence of splenomegaly .
Risk on mother : Petechiae, ecchymoses, and nose and gum bleeding , if PLT less than 20,000 significant bleding occur as hematuria, gastrointestinal bleeding , intracranial bleeding .
Risk ob baby : 12 - 15 % baby will had thrombocytopenia & less than 1 % complicated by intercranial hemorrhage .
ACOG Recommendations ..
ACOG Recommendations ..
When should women with ITP recieve treatment ?
If the patient is symptomatic & PLT count less than 50,000
What therapy should be used to treat ITP during pregnancy ?
-prednisone 1-2 mg \ kg\ day & they response within 2-3 days .
- IVIG if pt not responed to prednisone or in special conditions e.g. :
PLT less than 10,000 .
PLT less than 30,000 & patient has bleeding .
Pre operative , & they response as early as 6 hrs after .
- Splenectomy is associated with complete remission & done if possible if patient not responding to prednisone or IVIG .
- PLT transfusion .
ACOG Recommendations ..
What additional care should women with ITP recieve ?
- Avoid NSAIDs , Salicylates & trauma .
- If patient has splenectomy sholud be immunizes against : meningiococci , pneumococci , H.influnzae .
Can a patient with thrombocytopenia givin regional anasthesia ?
- patient can undergo regional anasthesia unless PLT is less than 50,000 because of the risk of hematoma .
Summary ..
Summary ..
Maternal thrombocytopenia between 100 x 109/L and 149 x 109/L in asymptomatic pregnant women with no history of bleeding problems is usually due to gestational thrombocytopenia.
Consensus guidelines recommend platelet transfusion to increase the maternal platelet count to more than 50,000 before major surgery.
Epidural or spinal anesthesia is considered acceptable in patients with platelet counts greater than 50,000
Fetal–neonatal alloimmune thrombocytopenia should be suspected in fetal or neonatal thrombocytopenia, hemor- rhage, or ultrasonographic findings consistent with intracranial bleeding.