Thrombocytopenia during pregnancy


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Thrombocytopenia during pregnancy

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Thrombocytopenia during pregnancy

  1. 1. Thrombocytopenia During pregnancy Prof Aboubakr Elnashar Benha university Hospital, Egypt Aboubakr Elnashar
  2. 2. Causes 1. Spurious result (reduced platelets on automated Coulter counter {platelet clumping or misreading of large immature platelets as red cells} 2. Gestational thrombocytopenia 3. Immune thrombocytopenic purpura (ITP) 4. Pre-eclampsia and Haemolysis, Elevated Liver enzymes and Low Platelets (HELLP) syndrome 5. Disseminated intravascular coagulation (DIC) Aboubakr Elnashar
  3. 3. 6. Haemolytic uraemic syndrome (HUS) /thrombotic thrombocytopenic purpura (TTP) 7. Sepsis 8. Human immunodeficiency virus (HIV), drugs and infections (e.g. malaria) 9. Systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) 10. Bone marrow suppression. Aboubakr Elnashar
  4. 4. Incidence  5-10%: of pregnant women Gestational' thrombocytopenia:75% Chronic ITP: 1-2/10,000 pregnancies. usually affects young Women female to male ratio = 3:1 Aboubakr Elnashar
  5. 5. AIloimmune thrombocytopenia fetal disorder {fetomaternal incompatibility for platelet antigens (similar to Rhesus haemolytic disease of the newborn)} No maternal symptoms and the mother is not thrombocytopenic. The condition develops in utero, affects all children including the firstborn, but is usually (except in the case of Subsequent siblings) diagnosed after birth. Incidence: 1 in 2000 causes 10% of all cases of neonatal thrombocytopenia. Aboubakr Elnashar
  6. 6. Clinical features Gestational thrombocytopenia: Benign condition platelet count <100 x 109/L: no adverse consequences for mother or baby. Thrombocytopenia in the first half of pregnancy: less likely to be gestational: possible diagnosis of ITP. Aboubakr Elnashar
  7. 7.  ITP Isolated thrombocytopenia without any associated haematological abnormality. No splenomegaly or lymphadenopathy. Haemorrhage: unlikely with platelet counts >50 x 109/L Spontaneous haemorrhage without surgery: unlikely with counts >20 x 109/L. ±skin bruising or gum bleeding severe haemorrhage: rare. Aboubakr Elnashar
  8. 8. Pathogenesis Gestational thrombocytopenia Normal pregnancy: Platelet count fall progressively 5% to 10%: thrombocytopenic levels (50-150 x 109/L) by term.  ITP Autoantibodies against platelet surface antigens: peripheral platelet destruction by the reticuloendothelial system, particularly the spleen. Aboubakr Elnashar
  9. 9. Diagnosis ITP By exclusion: other causes (infection and PET) Bone marrow: normal or megakaryocytic not necessary in pregnancy in cases of isolated thrombocytopenia unless it is severe (platelet count <30 x 109/L) Antiplatelet antibody: not readily available not helpful {absence of antiplatelet antibodies does not exclude the diagnosis of ITP.} Aboubakr Elnashar
  10. 10. Effect of pregnancy on ITP Pregnancy does not affect the course of ITP Anxieties arise around the time of delivery {possible bleeding associated with vaginal and abdominal delivery and regional anaesthesia and analgesia}. Aboubakr Elnashar
  11. 11. Effect of ITP on pregnancy Capillary bleeding and purpura: unlikely with a platelet count of >50 x 109/L Spontaneous mucous membrane bleeding: not a risk with platelet counts >20 x 109/L. Aboubakr Elnashar
  12. 12. Antiplatelet IgG can cross the placenta: fetal thrombocytopenia. Prediction of the fetal platelet count from maternal platelet count antibody level or splenectomy status: not possible Fetal platelet counts <50 x 109/L: 5% to 10% 10-15% in: ITP before pregnancy symptomatic ITP in the index pregnancy. Aboubakr Elnashar
  13. 13. Antenatal or neonatal intracranial haemorrhage 0% to 1.5% lowest in the absence of maternal symptoms or a history of ITP prior to the index pregnancy. One of the best predictors of severe neonatal thrombocytopenia is a previously affected child Incidence of serious haemorrhage in the fetus and neonate: low. Aboubakr Elnashar
  14. 14. Management Gestational thrombocytopenia Benign condition: no intervention. Aboubakr Elnashar
  15. 15. ITP Maternal considerations Exclude associated conditions: SLE (ANA, double stranded DNA, smith) or APS. The platelet count should be monitored monthly and then more frequently in 3rd T: therapy can be instituted if required prior to delivery. Treatment is only required in 1st and 3rd T: The woman is symptomatic with bleeding The platelet count is <20 x 109/L The count needs to be increased prior to a procedure such as chorionic villous sampling (CVS) Aboubakr Elnashar
  16. 16. Counts: <50 x 109/L (even in the absence of bleeding): prophylactic treatment prior to delivery. 50 to 80 x 109 /L may warrant treatment prior to delivery {facilitate safe regional analgesia}. Aboubakr Elnashar
  17. 17. CS: only required for obstetric indications Epidural and spinal anaesthesia: safe with stable counts >75 to 80 x 109/L. Bleeding time does not predict haemorrhage and is not indicated‘ Aboubakr Elnashar
  18. 18. Corticosteroids: first-line therapy Prednisolone dose: Non pregnant: (60-80 mg/d, 1 mg/kg/d) Pregnancy: lower doses (20-30 mg/d): safe and effective. then dose may be weaned to the lowest that will maintain a satisfactory (>50 x 109/L) maternal platelet count Aboubakr Elnashar
  19. 19. IV immunoglobulin (IVIg) Indication: resistant cases women likely to require prolonged therapy women requiring a high maintenance dose of prednisolone or who are intolerant of prednisolone.  Mechanism: delaying clearance of IgG-coated platelets from the maternal circulation. Aboubakr Elnashar
  20. 20. Response: more rapid (24-48 h) than with steroids: useful if a rapid response is required. lasts for two to three weeks Disadvantages: Expensive seldom produces long-term remission. Dose: 0.4 g/kg/ day for five days or 1 g/kg over eight hours, repeated two days later if there is an inadequate response. Aboubakr Elnashar
  21. 21. Anti-D immunoglobulin Indication: non-splenectomised rhesus-positive women. Mechanism: creating a decoy to competitively inhibit the destruction of antibody-coated platelets: raise platlet count. Doses: IV bolus 50 to 70 µg/kg. Safe and effective in 2nd and 3rd T. Monitor baby neonatal jaundice anaemia, and direct antiglobulin test positivity after delivery. Aboubakr Elnashar
  22. 22. Splenectomy should be avoided in pregnancy if possible May be necessary in extreme cases. Performed in the second trimester and can at this stage be performed laparoscopically. Women with ITP who have previously been treated with splenectomy should continue penicillin prophylaxis throughout pregnancy. Aboubakr Elnashar
  23. 23. Other options for women who fail to respond to oral prednisolone and IVIg i.v. methylprednisolone azathioprine or ciclosporin. danazol and vincristine: Although not recommend have been successfully used for severe resistant cases in pregnancy. Aboubakr Elnashar
  24. 24. Platelet transfusions last resort for bleeding or prior to surgery increase antibody titres do not result in a sustained increase in platelet counts. Aboubakr Elnashar
  25. 25. Fetal considerations No place for serial fetal blood samples earlier in gestation {Transfer of IgG increases at the end of pregnancy and the baby is not at risk of bleeding before labour and delivery} The risk of fetal blood sampling via cordocentesis (cord spasm, haemorrhage from the cord puncture site) is similar (or even higher in thrombocytopenic fetuses) to the risk of intracerebral haemorrhage (ICH). Aboubakr Elnashar
  26. 26. CS: only indicated for obstetric reasons. {no conclusive evidence that SC reduces the incidence of ICH, or that it is less traumatic for the fetus than vaginal delivery} Aboubakr Elnashar
  27. 27. Neonatal consideration Cord platelet count is determined immediately after delivery Neonatal platelet count: only reaches a nadir after two to five days in affected infants {splenic circulation is established}: most hemorrhagic events in neonates occur 24-48h after delivery at the nadir of the platelet count: monitoring is necessary over this time. IVIg the recommended treatment for neonates with bleeding or severe thrombocytopenia; this may be given prophylactically if the platelet count of the cord blood is low «20 x 109 /L). Aboubakr Elnashar
  28. 28. Conclusion ITP The diagnosis of ITP is one of exclusion and should only be made once other causes of thrombocytopenia have been excluded. Bleeding is unlikely if the platelet count is >50 x 109/L. The risk of serious thrombocytopenia and haemorrhage in the neonate from transplacental passage of antiplatelet IgG is low.  CS is only required for obstetric indications and epidural and spinal anaesthesiajanalgesia are safe with stable counts >75 to 80 x 109/L. Treatment, if required, should be with corticosteroids or IVIg). Aboubakr Elnashar
  29. 29. History and Physical Normal Repeat platlet count normal - Assume lab error - No further workup 1st T platlet count low Assume ITP Counsel: risks of neonatal thrombocytopenia Inform anesthesia and pediatric staff Ensure no spontaneous bleeding Ensure platelets >50K at delivery 1st T platlet count normal Assume gestational thrombocytopenia: no further work up Abnormal Aboubakr Elnashar
  30. 30. Abnormal History of medications -Alternative medication - Counsel maternal an fetal risk Evidence of systemic disease Management depend on type of illness e.g. self limiting viral illness or ch rheumatologic dis Elevated BP with normal BP in 1st T Assume hypertensive disorder of pregnancy Management depend on gest age and s and s of maternal and f disease Aboubakr Elnashar
  31. 31. Thanks Aboubakr Elnashar