Thrombocytopenia in pregnancy: Difference between revisions
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− | == |
+ | == Background == |
+ | ===Definition=== |
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+ | ==Clinical Manifestations== |
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+ | {| class="wikitable" |
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− | == Common Causes == |
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− | {| |
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− | ! |
+ | !Clinical Features |
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+ | |[[Gestational thrombocytopenia]] |
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+ | |5-9 |
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+ | |Onset 2nd-3rd trimester. Normal PLT previously. No neonatal thrombocytopenia. |
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+ | |Plt >70 |
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+ | |Typically normal |
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+ | |Unclear |
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+ | |Diagnosis of exclusion. Resolves postpartum. No fetal thrombocytopenia. |
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+ | |[[ITP]] |
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+ | |<1 |
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+ | |Onset any trimester. May see thrombocytopenia outside pregnancy. |
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+ | |Plt <100 +/- large platelets |
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+ | |May have bleeding, bruising, petechiae |
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+ | |Antibody-mediated peripheral plt destruction with decrease thrombopoiesis. |
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+ | |Diagnosis of exclusion. May be associated with fetal thrombocytopenia. |
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+ | |[[Preeclampsia]] |
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+ | |5-8 |
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+ | |Onset late 2nd or 3rd trimester (>20 weeks). |
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+ | |Proteinuria >0.3 g/d |
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+ | |BP ≥140/90 |
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+ | |Systemic endothelial dysfunction. Inadequate placentation. |
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+ | |May precede other manifestations of preeclampsia. Can present postpartum. |
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+ | |[[HELLP]] |
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+ | |<1 |
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+ | |70% late 2nd or 3rd trimester, 30% postpartum. |
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+ | |MAHA, high liver enzymes, high LDH. |
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+ | |Signs of preeclampsia, but may be normotensive without proteinuria. |
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+ | |Same as preeclampsia. |
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+ | |Variant of preeclampsia. |
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+ | |[[AFLP]] |
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+ | |<0.01 |
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+ | |Onset in 3rd trimester. |
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+ | |Plt >50. High liver panel, creat, WBC, urate, ammonia. High PT/PTT, decreased fibrinogen. Hypoglycemia. |
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+ | |RUQ pain. Jaundice, nausea/vomiting. Hepatic encephalopathy. |
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+ | |Preeclampsia spectrum. |
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+ | |MAHA not characteristic. Conjugated bili often high. Liver dysfunction greater than HELLP/preeclampsia. |
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+ | |[[TTP]]/[[aHUS]] |
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+ | |<0.01 |
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+ | |Onset any trimester, but more common during 3rd or postpartum. |
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+ | |MAHA, elevated creatinine, schostocytes on blood film. |
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+ | |Fever, abdo pain, n/v, headache, vis changes, altered mental status. |
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+ | |Congenital deficiency of ADAMTS13 (TTP) or complement dysregulation (aHUS). |
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+ | |ADAMTS13 activity <5% in TTP. Liver panel and BP usually normal. |
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+ | |}<br /> |
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− | == |
+ | ==Management== |
− | * |
+ | *Depends on etiology |
− | * |
+ | *Gestational thrombocytopenia |
− | ** |
+ | **No specific management |
+ | *[[Immune-mediated thrombocytopenia#Management|ITP]] |
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− | * ITP |
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− | ** |
+ | **No need to treat until 36 weeks if platelets over 30 |
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+ | **If platelets < 30 or bleeding |
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+ | ***[[Prednisone]] (0.25-1 mg/kg) or [[IVIg]] (1 g/kg ideally body weight, max 60mg) |
− | ** |
+ | **Monitor newborn for post-partum thrombocytopenia |
− | == |
+ | ==Prognosis== |
− | * |
+ | *In [[ITP]], 25% of neonates will have thrombocytopenia and 10% will need treatment |
[[Category:Hematology]] |
[[Category:Hematology]] |
Latest revision as of 09:07, 2 August 2020
Background
Definition
- Low platelet count in pregnancy, generally considered to be less than 100
Pathophysiology
- Most commonly, thrombocytopenia of pregnancy is caused by dilution from increased plasma volume, similar to anemia in pregnancy, and is usually more noticeable in T2 and T3
Etiology
- Gestational thrombocytopenia of pregnancy (70%)
- Hypertensive disorders (20%)
- Immune disorders (5%)
- Other (5%)
Epidemiology
- About 10% of pregnant women have platelets less than 150
Clinical Manifestations
Disease | % | Diagnostic Features | Lab Findings | Clinical Features | Pathophys | Comments |
---|---|---|---|---|---|---|
Gestational thrombocytopenia | 5-9 | Onset 2nd-3rd trimester. Normal PLT previously. No neonatal thrombocytopenia. | Plt >70 | Typically normal | Unclear | Diagnosis of exclusion. Resolves postpartum. No fetal thrombocytopenia. |
ITP | <1 | Onset any trimester. May see thrombocytopenia outside pregnancy. | Plt <100 +/- large platelets | May have bleeding, bruising, petechiae | Antibody-mediated peripheral plt destruction with decrease thrombopoiesis. | Diagnosis of exclusion. May be associated with fetal thrombocytopenia. |
Preeclampsia | 5-8 | Onset late 2nd or 3rd trimester (>20 weeks). | Proteinuria >0.3 g/d | BP ≥140/90 | Systemic endothelial dysfunction. Inadequate placentation. | May precede other manifestations of preeclampsia. Can present postpartum. |
HELLP | <1 | 70% late 2nd or 3rd trimester, 30% postpartum. | MAHA, high liver enzymes, high LDH. | Signs of preeclampsia, but may be normotensive without proteinuria. | Same as preeclampsia. | Variant of preeclampsia. |
AFLP | <0.01 | Onset in 3rd trimester. | Plt >50. High liver panel, creat, WBC, urate, ammonia. High PT/PTT, decreased fibrinogen. Hypoglycemia. | RUQ pain. Jaundice, nausea/vomiting. Hepatic encephalopathy. | Preeclampsia spectrum. | MAHA not characteristic. Conjugated bili often high. Liver dysfunction greater than HELLP/preeclampsia. |
TTP/aHUS | <0.01 | Onset any trimester, but more common during 3rd or postpartum. | MAHA, elevated creatinine, schostocytes on blood film. | Fever, abdo pain, n/v, headache, vis changes, altered mental status. | Congenital deficiency of ADAMTS13 (TTP) or complement dysregulation (aHUS). | ADAMTS13 activity <5% in TTP. Liver panel and BP usually normal. |
Investigations
- CBC and blood film
- Look for bicytopenia concerning for thrombotic microangiopathy
- Platelets <70 more consistent with ITP than gestational thrombocytopenia
- For ITP
- HIV, HBV, HCV
- Liver and thyroid tests
- Immunoglobulin levels
- DAT
- APLA and ANA
- Platelet antibody testing is useless
Management
- Depends on etiology
- Gestational thrombocytopenia
- No specific management
- ITP
- No need to treat until 36 weeks if platelets over 30
- If platelets < 30 or bleeding
- Prednisone (0.25-1 mg/kg) or IVIg (1 g/kg ideally body weight, max 60mg)
- Monitor newborn for post-partum thrombocytopenia
Prognosis
- In ITP, 25% of neonates will have thrombocytopenia and 10% will need treatment