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
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
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
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
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!
