thrombocytopenia in pregnancy...jan 13, 2017 · thrombocytopenia •6-12% of pregnancies in third...
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Thrombocytopenia
In
Pregnancy
Amy Sullivan, MD
Maternal-Fetal Medicine
January 13, 2017
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Normal Pregnancy
• 150,000 – 450,000
• Remains stable throughout pregnancy
• Slight decrease in some patients
• Remains within normal limits
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Thrombocytopenia
• 6-12% of pregnancies in third trimester
• Second most common hematologic
disorder in pregnancy
• Important to determine the etiology to
optimize clinical outcome
• Maternal and neonatal implications
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Gestational AutoImmune Systemic Infection Drugs
Primary
(ITP)
HELLP HCV Antimicrobials
Pseudo-
thmbocytopenia
Secondary TTP/HUS HIV Anti-epileptic
APS DIC CMV Analgesics
SLE EBV HIT
(Heparin)
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Drug Induced Thrombocytopenia Reese et al. Blood. 2010 Sep 23
Abciximab
Acetaminophen
Amiodarone
Ampicillin
Carbamazepine
Eptifibatide
Ethambutol
Haloperidol
Ibuprofen
Naproxen
Oxaliplatin
Phenytoin
Piperacillin
Quinidine
Quinine
Ranitidine
Rifampin
Simvastatin
Sulfisoxazole
Trimethoprim-sulfamethoxazole
Valproic acid
Vancomycin
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Gestational AutoImmune Systemic Infection Drugs
Primary
(ITP)
HELLP HCV Antimicrobials
Pseudo- Secondary TTP/HUS HIV Anti-epileptic
APS DIC CMV Analgesics
SLE EBV HIT
(Heparin)
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Evaluation
• Detailed history
• Medical, family, medication
• Clinical Scenario
• Gestational age, viral illness, HTN
• Peripheral smear
• Rule out pseudo-thrombocytopenia
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Gestational Thrombocytopenia
• 10% of pregnancies
• 80% of all cases of thrombocytopenia
• Mild thrombocytopenia (> 70,000)
• No history of thrombocytopenia / bleeding
• Later in gestation
• Not associated with fetal thrombocytopenia
• Resolves spontaneously post partum
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Immune Thrombocytopenia
(ITP)• 1:1,000 pregnancies
• 1-4% cases of thrombocytopenia
• Thrombocytopenia more profound
• Often have a bleeding history
• Persists post partum
• May cause neonatal thrombocytopenia
and hemorrhage
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Gestational vs ITP?
• Distinction between mild ITP and
gestational thrombocytopenia may NOT
be possible.
• No laboratory tests to differentiate
• Both demonstrate anti-platelet antibodies
• Immunologic etiology
• Clinical overlap
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Gestational vs ITP
• ITP may have implications for neonate
• Anti-platelet IgG antibodies cross placenta
• Risk for neonatal thrombocytopenia:
• Plts < 50,000: 10-15%
• Platelets < 20,000: 5%
• Risk for intracranial hemorrhage <1.5%
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Clinical Case
25 year old G2P1001 with scant prenatal
care, found to have a platelet count of
75,,000 at 30 weeks gestation. Her first
pregnancy was uncomplicated, but
remembers her platelets were “low.” Never
had post partum follow up. No history of
bleeding. Negative family history. Repeat
platelet count at 32 weeks: 60,000.
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Evaluation
• History unremarkable
• Peripheral smear normal
• +/- viral titers (normal)
• ITP or gestational?
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Pregnancy Management
• Monitor platelet counts
• ? Frequency
– Q trimester
– Q weekly
• Neither GT nor ITP is an indication for c/s
• Fetal umbilical cord sampling not indicated
• If patient is asymptomatic: goal is to
prepare for delivery.
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Risk of Maternal Bleeding
• Minimal if platelets > 50,000 (c/s)
• Minimal if platelets > 30,000 (vaginal)
• Regional anesthesia
• Always consider need for c/s
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Treatment Initial Onset(days)
Peak Onset(days)
Prednisone 4-14 7-28
Dexamethasone 2-14 4-28
IVIG 1-3 2-7
Platelet Tx immediate
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Treatment
• Prednisone (1mg/kd/day)
– Slow taper to maintain platelet count
• Prednisone 10-20 mg QD starting 10
days prior to delivery
• Dexamethasone 40 mg/day x 4 days – Wei et al. Blood March 25, 2016
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Delivery
• C/S not indicated for GT or ITP
– Vacuum / forceps relative contraindication
– Forceps lower risk of cephalohematoma
• Neuroaxial analgesia
• Precise platelet count not known
– >80,000
– Varies by institution
– Be familiar with local guidelines !
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Post partum
• Alert pediatricians
– Neonatal platelet count may continue to drop
post partum
• Unclear diagnosis?
– Repeat maternal platelet count 2-3 months
post partum
– Recurrence risk unknown
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Summary
• Thombocytopenia 10% of pregnancies
• Majority of cases etiology is evident
• Don’t overlook:
• Pseudo thrombocytopenia, drug induced
induced, viral
• Distinguish between mild ITP and GT
may not be necessary
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Summary
• Risk of maternal hemorrhage is low
• Risk of neonatal ICH is low
• Preparation for delivery
– Steroids
– IVIG
– Platelet transfusion (if actively bleeding)
• POST PARTUM FOLLOW UP