Thrombocytopenia in Pregnancy A clinical case review

• I.G.,
• 35 years,
• GIVPI,
• Maried,
• One son,
• Natural from Georgia,
• Living in Portugal.

Severe thrombocytopenia

• Cronical Hepatitis C.
• No other relevant previous background.

• I.O. 0.1.2.1
• 2 spontaneous abortions before 1997,
without complications.
• 1 pre-term vaginal birth in 1997, female,
2000gr, in Georgia.

• Irrelevant

• Pregnant women of 34 weeks of gestation referred to
the emergency because of platelets count of
21.000/µL – 2nd May 2009.
• Actual pregnancy:
› Last menstruation:05/09/2008 EDD: 12/06/09.
› Uneventful - without ultrasound changes.
› Amniocentesis: normal cariotype 46,XY.
› Blood tests: immune to rubella and toxoplasmosis. AtgHBs, HIV
and VDRL negative. HCV positive. Concentration of platelets in
the first trimester of 120.000/µL.

• Completely asymptomatic and without personal
history of another similar occurrence, including in
previous pregnancies. Without usual medication.
• Physical Examination:
› Colored and hydrated, without petechiae or ecchymosis.
No mucosal bleeding or melena. The abdomen was soft,
not painful without hepatosplenomegaly.
• It started therapy with prednisolone 1mg/kg/day
and was admitted in 2nd May 2009.

• During the hospitalization she remained
asymptomatic and with normal blood pressure.
• Serologies were made with negativity for HBsAg, HIV
and VDRL, immunity to CMV and HCV viral loads
were minimum (34564 IU / ml).
• Normal kidney and hepatic function.
• Anti-nuclear and Anti-phospholipidic antibodies were
requested. They turned out negative. The antiplatelet
antibodies were also negative.

• The abdominal ultrasound revealed a liver with
regular shape and a large nodular calcification in
the right lobe (probably sequelae) and mild
homogeneous splenomegaly. No other changes
were encountered.
• On 9th May she was discharged with platelets
count of 48.000/µL and 60 +20 mg of prednisolone.

• She returned to the hospital for analytical
control in 13th May, at that time the
platelets count was 26.000/µL;
• Prednisolone was increased to initial
dosage – 60+30 mg;
• Poor adherence to therapy versus
unresponsive to treatment?

• On 20th May she entered in emergency
room in labour with amniotic rupture. At
that time platelets count was of 31.000/µL.
• Labour:
› 20th May at 13h19m with GA of 37 weeks.
› Vaginal birth, loose cervical circular and midlateral
right episiotomy.
› Masculine newborn, with 3470gr. Apgar 1’= 10.
› The newborn was discharged by the
pediatrician at the 2nd day of life without
complications.

• Definition: platelets count in peripheral
blood less than150.000/µL. It complicates
7 to 8% of all pregnancies.
• Categories:
› Light – 100000 a 150000/µL;
› Mild – 50000 a 100000/µL;
› Severe - <50000/µL.

• Frequent etiologys:
› Gestacional thrombocytopenia – 70% (70.000-100.000/µL);
› HELLP Syndrome – 21% (usualy platetlets count >20.000/µL <100.000/µL) – Blood
pressure rise and proteinuria can be absent;
› Idiopathic thrombocytopenic purpura (ITP) – 3% (5.000-75.000/µL).

• Other etiologies:
› Pseudothrombocytopenia - laboratory artifact due to the
presence of platelet aggregates;
› Microangiopathy - Trombotic Thrombocytopenic Purpura (TTP)
and hemolytic uremic syndrome (HUS);
› SLE and other autoimmune diseases
› Viral infections (particularly CMV and HIV);
› Hypersplenism;
› Medications (heparin, zidovudine, methyldopa);
› Massive obstetric hemorrhage and detachment of the placenta;
› Sepsis;
› Folate deficiency;
› Aplastic anemia;
› Allergy.

• Detailed clinical history of personal background including previous pregnancies, allergy and drug habits.
• Physical examination with y particular attention to equimoses, petechiae, mucosal bleeding, melena, kidney or neurological disorders. Measurement of blood pressure.
• Abdominal ultrasound - exclusion of splenomegaly and associated liver pathology;
• Analytical study:
› With blood platelets count and blood smear;
› Hepatic function / LDH / creatinine / BUN / total and direct bilirubin;
› Antinuclear and antiplatelet antibodies;
› Determination of folic acid;
› Serology for CMV and HIV.

• If platelets <50.000 and / or abnormal bleeding and / or invasive procedures (such
as cesarean section or locoregional anesthesia):
› Prednisolone 1mg/kg/day - in a slowly decreasing in order to maintain platelets count above 50.000 - response time of 3 to 7 days.
› Gamma-globulin 400mg/kg/day - ideal in cases where there is a need for immediate increase of platelets (response time of between 6-72h) such as a surgery or bleeding;
› Anti-D immunoglobulin – in pregnant women rh positive, non-splenectomized;
› Splenectomy - if in 1st or 2nd trimester with platelets count <10,000 and
refractory to steroids or gamma globulin;
• Platelets transfusion:
› If severe bleeding;
› Platelets must be reserved before surgery;
› Administer 6-10 units – there is an increase of 10.000 platelets for each unit of
platelet concentrate transfused.

• There is no absolute indication for cesarean section, only because of thrombocytopenia;
• Cesarean section should be reserved for obstetric indications;
• Neither one of the routes of delivery is associated with a known higher incidence of fetal intracranial hemorrhage;
• Blood should be taken from umbilical cord (when possible) for platelet count of the newborn – risk of thrombocytopenia in newborns is greater in ITP.

• The physician must always document the normalization of platelets count - which should occur in cases of gestational thrombocytopenia or in the HELLP syndrome.

• The distinction between gestational thrombocytopenia and idiopathic thrombocytopenic purpura is difficult.
• The normalization of platelets count in the gestational thrombocytopenia occurs in the first 2-12 weeks after delivery and its recurrence in subsequent pregnancies is rare.