HOW Collaborative position paper on thrombocytopenia in pregnancy

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!