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HOW Collaborative position paper on thrombocytopenia in pregnancy

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HOW Collaborative position paper on the management of thrombocytopenia in pregnancy

Position paper published in ANZJOG Jan 2021.

https://doi.org/10.1111/ajo.13303

Causes

  • Gestational (70-80%)
  • Primary immune thrombocytopenia (ITP) (1-2%)
  • Secondary ITP, eg due to human immunodeficiency virus (HIV), hepatitis C, systemic lupus erythematosus
  • Congenital
  • Drug-induced
  • Type IIb von Willebrand’s disease (VWD)
  • Antiphospholipid syndrome
  • Splenic sequestration, eg liver disease, portal hypertension
  • Bone marrow disorders
  • Nutritional deficiency, eg vitamin B12/folate
  • Pregnancy-associated microangiopathy
    • Preeclampsia/haemolysis, elevated liver enzymes, low platelets syndrome (HELLP)
    • Thrombotic thrombocytopenic purpura (TTP)
    • Haemolytic uraemic syndrome (HUS)
    • Acute fatty liver of pregnancy
    • Sepsis
    • DIC
    • Spurious/Pseudothrombocytopenia (clumping)


      • Initial investigations (if platelet count <70)

      • Full blood count and reticulocyte count
      • Peripheral blood film
      • Optical platelet count (if available)
      • Coagulation screen
      • Renal and liver function tests
      • Thyroid function tests
      • Direct Coombs test
      • Antiphospholipid antibodies: lupus anticoagulant, anticardiolipin antibodies, beta 2 glycoprotein 1 antibodies
      • Antinuclear antibody (ANA)
      • Hepatitis B/C and human immunodeficiency virus (HIV) serology
      • Helicobacter pylori
      • Vitamin B12/folate
      • Immunoglobulins


        • Management

        • Monthly platelet count in pregnancy, fortnightly if <100 from 36 weeks
        • Withhold aspirin if platelets <50
        • IM injections contraindicated if platelets <50 (Give IV Rhophylac instead of Anti-D)
        • Treatment indications: Platelets <20, Bleeding attributed to low platelets, Platelets <50 and pre-procedure (surgery/CVS)/birth imminent/planning neuraxial anaesthesia with platelets <70


          • Regimens

          • IVIG and prednisone are equally effective first-line treatments
            • Start with 20-25 mg prednisone PO daily
            • 40-50 mg prednisone PO daily for platelets <20 or acute bleeding
            • Response takes 4-28 days
            • Prednisone side effects: GDM exacerbation, hypertension, poor sleep, gastritis, mood disturbance
            • IVIG indicated for life-threatening haemorrhage around delivery
            • 1-2 g/kg as single or divided dose
            • Response 2-7 days
            • Adverse effects: transfusion reaction, headache, aseptic meningitis, thrombosis


              • Labour and birth

              • Platelets <100: MDT approach, Birth in hospital, Induce at term
              • Target platelets >50 for: Vaginal birth, Instrumental, Caesarean, Clexane use
              • Target platelets >70 for allow regional anaesthesia (spinal is less traumatic than epidural)
              • Stress steroids in labour: IV hydrocortisone 50 mg Q6H from established labour to 6 hours after birth. For caesarean, give 100 mg IV hydrocortisone at time of anaesthesia, then 6 hours post-birth
              • Mode of birth: Lack of data to inform instrumental risks. ITP is associated with a small increase in neonatal thrombocytopaenia.


                • This podcast is not endorsed by RANZCOG/ANZJOG and has no affiliation with RANZCOG/ANZJOG. This podcast does not constitute medical advice and comes with no assurance of accuracy. Amazing cover artwork by Anna Lovisa - Ngā mihi nui!

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