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Physiologic Changes
Published in Vincenzo Berghella, Obstetric Evidence Based Guidelines, 2022
The most difficult differential usually comes down to gestational thrombocytopenia versus ITP. These conditions cannot be reliably differentiated with antiplatelet antibody testing or any other diagnostic test. A platelet count <100,000/µL is typically more concerning for ITP, and a platelet count <50,000/µL is almost certainly ITP as opposed to gestational thrombocytopenia [27]. In order to be classified as gestational thrombocytopenia, several conditions must be satisfied. Gestational thrombocytopenia is mild, with platelet counts typically greater than 75,000/µL. There is no history of significant bleeding and no history of thrombocytopenia prior to pregnancy. Platelet counts generally return to normal within 4–8 weeks following delivery, and there is an extremely low risk of fetal or neonatal thrombocytopenia. ITP is a clinical diagnosis and a diagnosis of exclusion of other systemic disorders known to be associated with thrombocytopenia. Although it can be associated with elevated antiplatelet antibodies, this is not a recommended part of the diagnostic evaluation [27].
Haematological system
Published in Pankaj Desai, Pre-eclampsia, 2020
The occurrence of thrombocytopenia in 5% of pregnant women at delivery, described as gestational thrombocytopenia, is well documented. A commonly believed concept is that gestational thrombocytopenia is the result of gradually decreasing platelet counts in all women during pregnancy.3 It is also noteworthy that even if the circulating platelet counts get reduced in pregnancy, the neonatal circulating platelets remain by and large unaffected.
Update on diagnosis and treatment of immune thrombocytopenia
Published in Expert Review of Clinical Pharmacology, 2021
Rajeev Sandal, Kundan Mishra, Aditya Jandial, Kamal Kant Sahu, Ahmad Daniyal Siddiqui
In pregnancy, differential diagnoses for thrombocytopenia include gestational thrombocytopenia, pregnancy-related hypertensive disorders like eclampsia, HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count). Once the diagnosis of ITP is established, the patient should be kept on close follow up for bleeding with target platelet count >30 × 109/L till term. The mode of delivery is guided by the obstetrician’s choice. For normal delivery, the platelet count should be kept >50 × 109/L, and for cesarean section it should be maintained >70 × 109/L for safe spinal anesthesia. Drugs preferred in pregnancy are IVIG and corticosteroids. Patients are usually started on prednisolone at 20 mg daily and the patient is kept on a minimum dose to maintain target platelets to avoid unnecessary side effects. IVIG at dose 1–2 gm/kg can be used if the fast response is required near term. Anti-D can be also used in non-splenectomized patients after documenting negative direct coombs test. In refractory cases, combination therapies comprising of high-dose corticosteroid (dexamethasone) with IVIG or azathioprine, or cyclosporine with azathioprine can be used. The published experience with TPO-RAs in pregnancy is limited to case reports only. Rituximab increases the risk of immunosuppression in the newborn, so its use is not recommended. If a patient needs splenectomy for refractory ITP, it should be preferably performed during the second trimester. Vinca alkaloids, mycophenolate and cyclophosphamide should not be used during pregnancy [7,8,12,181].
Pregnancy-associated aplastic anemia: a case-based review
Published in Expert Review of Hematology, 2021
José Carlos Jaime-Pérez, Mariana González-Treviño, David Gómez-Almaguer
The diagnosis of AA requires bone marrow hypocellularity with at least two of the following criteria: Hb <10 g/dL, neutrophils <1.5 × 109/L, and platelets <50 × 109/L [8]. However, pregnancy triggers physiological changes in the three peripheral blood cell lines. Estrogens increase plasma volume more than red-blood-cell production, resulting in dilutional anemia. This causes normal Hb levels to vary depending on the trimester [26]. Pregnancy may course with gestational thrombocytopenia, which is mild thrombocytopenia with platelets ≥100 x 109/L. If platelets are <100 x 109/L, a cause other than pregnancy should be considered [27]. It is well known that normal pregnancies course with leukocytosis. Some reports show that pregnant women with AA have an increase in neutrophils during pregnancy compared with pre-pregnancy values [6,28,29]. This could be a cause of confusion if significant neutropenia is expected in all pAA cases.
Unexplained haemolytic anaemia associated with pregnancy combined with severe gestational thrombocytopenia
Published in Journal of Obstetrics and Gynaecology, 2019
Jing Liu, Lu Ji, Guang Song, Tao Meng
Gestational thrombocytopenia is the commonest cause of thrombocytopenia during pregnancy, and is not associated with any adverse events for either mother or baby (McCrae et al. 1992; ACOG 2016). This is a diagnosis of exclusion. Although there are only very few reported cases of gestational thrombocytopenia with a very low platelet count, Win et al reported cases of more severe thrombocytopenia that showed no response to steroids, and resolved postnatally, which is consistent with gestational thrombocytopenia (Win et al. 2005). We considered immune thrombocytopenia (ITP) for the patient in our case at first, but the maternal platelet count recovered spontaneously postpartum. Thus, the diagnosis of pregnancy-associated ITP was incorrect in the light of subsequent events, demonstrating that evaluation of the outcome of pregnancy is important in making a correct diagnosis.