Thrombocytopenia in Pregnancy: Approach to Diagnosis and Management

2020 ◽  
Vol 46 (03) ◽  
pp. 256-263
Author(s):  
Annemarie E. Fogerty
Keyword(s):  
Platelet Count ◽  
Immune Thrombocytopenia ◽  
Thrombocytopenic Purpura ◽  
Gestational Thrombocytopenia ◽  
Life Threatening ◽  
Immune Thrombocytopenia Purpura ◽  
The Impact ◽  
Underlying Pathophysiology ◽  
In Pregnancy ◽  
Management Issues

AbstractThe impact of thrombocytopenia varies widely depending on the underlying pathophysiology driving it. The biggest challenge in managing thrombocytopenia in pregnancy is accurately identifying the responsible pathophysiology—a task made difficult given the tremendous overlap in clinical and laboratory abnormalities associated with different thrombocytopenia processes. The most common etiologies of thrombocytopenia in pregnancy range from physiology deemed benign to those that are life-threatening to the mother and fetus. Even in cases in which the responsible etiology is deemed benign, such as gestational thrombocytopenia, there are still implications for the management of labor and delivery, a time where hemostatic challenges may prove life-threatening. In most institutions, a minimum platelet count will be mandated for epidural anesthesia to be deemed a safe option. The causes of thrombocytopenia can also include diagnoses that are pregnancy-specific (such as preeclampsia or gestational thrombocytopenia), potentially triggered by pregnancy (such as thrombotic thrombocytopenic purpura), or unrelated to or predating the pregnancy (such as liver disease, infections, or immune thrombocytopenia purpura). It is imperative that the source of thrombocytopenia is identified accurately and expeditiously, as intervention can range from observation alone to urgent fetal delivery. In this review, the approach to diagnosis and the pathophysiological mechanisms of the most common etiologies of thrombocytopenia in pregnancy and associated management issues are presented.

Acute thrombocytopenia: picking a way through a paucity of platelets

2019 ◽  
Vol 80 (9) ◽  
pp. 507-512
Author(s):  
E Nuttall Musson ◽  
O Lomas ◽  
MF Murphy
Keyword(s):  
Platelet Count ◽  
Adult Patient ◽  
General Hospital ◽  
Disseminated Intravascular Coagulation ◽  
Immune Thrombocytopenia ◽  
Underlying Disease ◽  
Hospital Physician ◽  
Case Histories ◽  
Thrombocytopenic Purpura ◽  
In Pregnancy

Thrombocytopenia is defined as a platelet count under 150x109/litre. It may be found as a bystander to other pathology or directly related to an underlying haematological condition. Apart from laboratory artefact, it should be treated seriously as it often reflects serious underlying disease. This review uses short case histories to illustrate how to approach thrombocytopenia during the initial presentation of an adult patient to hospital. This article guides the general hospital physician through the narrow but potentially confusing differential diagnoses related to thrombocytopenia, with particular focus on immune thrombocytopenia, disseminated intravascular coagulation and thrombotic thrombocytopenic purpura. Thrombocytopenia in pregnancy deserves special consideration and will not be discussed in this article.

scholarly journals Study of thrombocytopenia in pregnancy: clinical presentation and outcome at tertiary care rural institute

2020 ◽  
Vol 9 (4) ◽  
pp. 1622
Author(s):  
Jigyasa Singh ◽  
Kalpana Kumari ◽  
Vandana Verma
Keyword(s):  
Platelet Count ◽  
Prospective Observational Study ◽  
Clinical Presentation ◽  
Tertiary Care ◽  
Late Pregnancy ◽  
Normal Platelet ◽  
Gestational Thrombocytopenia ◽  
Underlying Causes ◽  
In Pregnancy ◽  
Rule Out

Background: Platelet count below 1.5 lakh/cumm is called as thrombocytopenia. After anaemia it is the second most common haematological disorder in pregnancy. It affects nearly 6 to 15%; on an average 10% of all pregnancies. Gestational thrombocytopenia is a clinically benign thrombocytopenic disorder usually occurring in late pregnancy. It resolves spontaneously after delivery.Methods: It is a hospital based prospective observational study over a period of 1 year. All pregnant women who attended OPD at the department of obstetrics and gynecology, UPUMS, Saifai for antenatal checkup were included for the study and blood sample was withdrawn.Results: Out of 263 cases enrolled for study, 90 women were found to have thrombocytopenia, and 173 had normal platelet count. Thus, incidence of thrombocytopenia was 34%. Gestational thrombocytopenia accounted for majority of cases of thrombocytopenia in pregnancy (50%) followed by hypertensive disorders (22.4%). It was further followed by ITP (11.11%) and dengue (5.5%).Conclusions: Gestational thrombocytopenia is the most common cause of thrombocytopenia during pregnancy (50%), but other underlying causes must be considered as well. A thorough history and physical examination will rule out most causes.

scholarly journals How I treat thrombotic thrombocytopenic purpura in pregnancy

Blood ◽  
2020 ◽  
Vol 136 (19) ◽  
pp. 2125-2132
Author(s):  
Barbara Ferrari ◽  
Flora Peyvandi
Keyword(s):  
Differential Diagnosis ◽  
Thrombotic Thrombocytopenic Purpura ◽  
Current Knowledge ◽  
Fetal Outcome ◽  
Subsequent Pregnancy ◽  
Thrombocytopenic Purpura ◽  
Severe Deficiency ◽  
Life Threatening ◽  
High Index Of Suspicion ◽  
In Pregnancy

Abstract Thrombotic thrombocytopenic purpura (TTP) is an acute, life-threatening thrombotic microangiopathy (TMA) caused by acquired or congenital severe deficiency of ADAMTS13. Pregnancy is a recognized risk factor for precipitating acute (first or recurrent) episodes of TTP. Differential diagnosis with other TMAs is particularly difficult when the first TTP event occurs during pregnancy; a high index of suspicion and prompt recognition of TTP are essential for achieving a good maternal and fetal outcome. An accurate distinction between congenital and acquired cases of pregnancy-related TTP is mandatory for safe subsequent pregnancy planning. In this article, we summarize the current knowledge on pregnancy-associated TTP and describe how we manage TTP during pregnancy in our clinical practice.

Severe Immune Thrombocytopenia in Pregnancy: Intravenous Immunoglobulin Can Improve Platelet Count Significantly

2020 ◽  
Vol 36 (6) ◽  
pp. 368-371
Author(s):  
Mohamed Fouad Selim ◽  
Manal Mohammad Ali Abdou ◽  
Ali Mohamed Ali Elnabtity
Keyword(s):  
Platelet Count ◽  
Intravenous Immunoglobulin ◽  
Immune Thrombocytopenia ◽  
In Pregnancy

Autoimmune Thrombocytopenic Purpura Complicating Chronic Lymphocytic Leukemia: Analysis of 60 Patients.

Blood ◽  
2006 ◽  
Vol 108 (11) ◽  
pp. 4932-4932
Author(s):  
Carlo Visco ◽  
Roberto Stasi ◽  
Marco Ruggeri ◽  
Achille Ambrosetti ◽  
Stefania Fortuna ◽  
...  
Keyword(s):  
Platelet Count ◽  
Chronic Lymphocytic Leukemia ◽  
Complete Response ◽  
Lymphocytic Leukemia ◽  
Severe Thrombocytopenia ◽  
Short Term ◽  
Thrombocytopenic Purpura ◽  
Autoimmune Thrombocytopenic Purpura ◽  
Cytotoxic Treatment ◽  
The Impact

Abstract Autoimmune thrombocytopenic purpura (AITP) represents the autoimmune condition most frequently associated with chronic lymphocytic leukemia (CLL) after autoimmune haemolytic anemia. However, the main characteristics and outcome of AITP in the course of CLL, as well as the impact of this complication in the natural history of the tumor remain unknown. We identified 60 consecutive patients with CLL who developed AITP, representing 3,5% of CLL patients diagnosed in the three participating centers between 1995 and 2004. To be included in this study patients had to experience at least one episode of AITP, which was defined as the occurrence of acute and severe thrombocytopenia in the presence of normal or augmented number of megakariocytes in the bone marrow, without extensive lymphoid marrow infiltration, splenomegaly or recent cytotoxic treatment. A complete response (CR) to AITP treatment was defined by a platelet count > or = 150×10(9)/L, and a partial response (PR) by a platelet count > 50×10(9)/L or by an increase of at least twofold the initial level. Remaining patients were considered as no responders (NR). Median age of our 60 patients was 65 years (range 48–83) and 40 were males. At CLL presentation RAI stage was 0 to 2 in 88%, time to CLL treatment was 13,8 months (range 0–120), while first line treatment for CLL consisted of Chlorambucile alone (Chl) in 73% of patients with 18% of patients that received no treatment for their malignancy. Median overall survival was 57 months. AITP occurred concomitantly to CLL diagnosis in 13 patients (22%), while median time to AITP for remaining 47 patients was 30 months (range 2–147). The median platelet count at AITP diagnosis was 23 × 10(9)/L(range, 1–81). Twenty-five patients (42%) presented with moderate bleeding signs at AITP diagnosis, while 4 patients (7%) experienced severe hemorrhagic episodes, requiring hospitalization and blood transfusions. Fifty-two of the 60 patients (87%) received at least one treatment for AITP: 32 patients received i.v.Ig alone or in combination with steroids, leading to a short-term NR in 66% (CR 19%, PR 15%); nine patients underwent splenectomy and 7 (78%) experienced a durable CR; patients who were treated with chemotherapy (Chl, COP, CVP) +/− steroids had at least a PR in 73% of cases. With a median follow-up from AITP onset of 35 months, 17 of the 52 treated patients are still NR (33%) and 13 of them are on treatment. In our series of patients with CLL and AITP we observed an unexpectedly short survival regardless of a large prevalence of low RAI stages at diagnosis. Treatment of AITP with i.v. Ig +/− steroids leaded to a low rate of short-term responses, while splenectomy and chemotherapy seemed sufficiently adequate therapeutic approaches.

Autologous 111 Indium-Oxinate-Labelled Platelet Sequestration Study in Patients with Immune Thrombocytopenia Treated By Thrombopoietic Receptor-Agonists

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 2555-2555
Author(s):  
Matthieu Mahevas ◽  
Sandrine Van Eeckhoudt ◽  
Guillaume Moulis ◽  
Christine Dosquet ◽  
Marc Michel ◽  
...  
Keyword(s):  
Platelet Count ◽  
Life Span ◽  
Kinetic Study ◽  
Immune Thrombocytopenia ◽  
Complete Response ◽  
Splenic Sequestration ◽  
Platelet Production ◽  
Receptor Agonists ◽  
Day Range ◽  
The Impact

Abstract Introduction In immune thrombocytopenia (ITP), isotopic assessment of the site of platelet destruction using autologous111Indium-oxinate-labelled platelet sequestration study could be an helpful parameter to determine whether or not to perform splenectomy. Two independent studies have suggested that a purely splenic sequestration could be a significant predictive factor of long-term complete response after splenectomy. An increasing number of patients receives thrombopoietic receptor-agonists (TPO-RAs) but such treatments are not curative and therefore do not necessarily prevent from considering splenectomy in the course of ITP. TPO-RAs increase platelet production by inducing proliferation and differentiation of the megakaryocyte lineage. We have only very few data evaluating the impact of TPO-RAs, on mean platelet life span (MPLS), platelet production and platelet site of destruction. The aim of this study was to assess these parameters and clinical outcome of patients treated with TPO-RAs who underwent kinetic study of autologous111Indium-oxinate-labelled platelet. Patients and Methods We carried out a retrospective study in the Ile de France region, between 2008 and 2016. Patients were retrospectively selected from a prospective clinical database at the Cellular Biology Department of Saint Louis Hospital. We selected adult patients with definite ITP according to the international criteria. The isotopic method used to study platelet lifespan was previously described. Analyses were based on the radioactivity accumulation slopes in the hepatic or splenic area. We excluded patients who had received less than 3Mbeq of 111In. Data from patients' medical charts were collected using the standardized form of the Referral Center for Adult ITP. Complete response (CR) and Response (R) were defined according to standardized international criteria: platelet count > 30x 109/L with at least a doubling of the baseline value or >100 x 109/L. Results of platelet kinetic study from patients treated with TPO-RAs were compared with those from patients receiving no treatments. Results Two hundred and fifty three adults ITP patients were included. At the time of platelet kinetic study, 24 patients (10 men/14 women) with a median age of 63 years [range: 22-83] were treated with TPO-RAs (romiplostim n= 10, eltrombopag n = 14) and 229 (81 men/148 women) had no treatment. Among the TPO-RAs treated patients, some also received low dose steroids (n=6), dapsone (n=1) or intravenous immunoglobulins (n=2) at least two weeks before the kinetic study. Three were newly diagnosed, 9 had persistent ITP and 12 chronic ITP. The median platelet count was 62 x109/L [range: 22-175], and 7 patients had a platelet count > 100 x109/L. The median Mean Platelet Life Span (MPLS) was reduced in both groups (1.44 day [range: 0.4-7.5] (normal: 7-10) in patients treated with TPO-RAs), but was significantly higher in untreated patients (2.3 day [0.4-11], p = 0.004). The median turnover platelets ratio was increased in both groups (48% per day [range: 11-173] in patients treated with TPO-RAs), but was significantly lower in untreated patients (30% per day [range: 0.8-247]). Ratio of platelet production was significantly increased in patients treated with TPO-RAs (median: 2, [range: 0.1-5.0]) compared with untreated patients (median: 0.84, [range: 0.1-85.0]). Repartition of the site of platelet sequestration was similar in the two groups, 12 (50%) patients treated with TPO-RAs had a splenic uptake, versus 112 (49.1%) in untreated patients, and 2 (20%) patients treated with TPO-RAs had an hepatic uptake versus 9 (3.9%) in untreated patients. A splenectomy was performed in 9 out of the 12 patients with a purely splenic sequestration. After a median follow-up of 26 months [range 0-53], 8 (88%) had achieved CR and 1 had relapsed 5 months after splenectomy. Conclusion Our study shows that despite an increase production and turnover of platelets due to the stimulation of the megakaryopoiesis by TPO-RAs, the MPLS was clearly reduced and the repartition of platelet sequestration was not modified in patients receiving these drugs. Moreover, it would seem that a purely splenic sequestration is also predictive of CR after splenectomy in this group of patients. More importantly platelet kinetic study can be used in patients treated with TPO-RAs to position the splenectomy in the therapeutic management. Disclosures No relevant conflicts of interest to declare.

Effect of Pregnancy in Women with a History of Primary Immune Thrombocytopenia Considered As Cured

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 2552-2552
Author(s):  
Thibault Comont ◽  
Guillaume Moulis ◽  
Karen Delavigne ◽  
Pierre Cougoul ◽  
Olivier Parant ◽  
...  
Keyword(s):  
Platelet Count ◽  
Complete Remission ◽  
Epidural Analgesia ◽  
Pregnant Women ◽  
Immune Thrombocytopenia ◽  
Specific Treatment ◽  
Severe Bleeding ◽  
Adult Women ◽  
History Of ◽  
The Impact

Abstract Immune thrombocytopenia (ITP) is an autoimmune disease that occurs in young women. Pregnancy is a well-known risk factor for developing newly diagnosed ITP as well as for inducing disease flares in patients with current ITP. However, the impact of pregnancy in women with an old history of ITP, considered as cured, has not been assessed. The aim of this study was to describe the course of ITP in pregnant women with an ITP in complete remission (platelets count >100x109/L and absence of bleeding symptoms) for at least 5 years without any ITP treatment. We retrospectively selected all pregnant women with delivery at Toulouse University Hospital, South of France, between 2010 and 2015 with a hospital discharge code of ITP (international classification of diseases; version 10 code D69.3). This code has a sensitivity of 81.2% and a positive predictive value of 89.8% in this database. All medical charts were reviewed to confirm the diagnosis of ITP. We included adult women (≥18 years) with a diagnosis of primary ITP according to French guidelines (platelet count <150 x 109 /L and exclusion of other causes of thrombocytopenia, especially other causes of thrombocytopenia during pregnancy) in complete remission for at least 5 years. We identified 50 pregnancies in 39 ITP patients during the study period. Eleven pregnancies occurred in 10 patients in long-term complete remission of ITP at the time of pregnancy onset. Baseline characteristics were: median age at ITP diagnosis: 21 years (range: 4-29); median age at pregnancy onset:32 years (range: 26-34; history of ITP during a previous pregnancy: 1; history of bleeding: 4 (36.4%); previous treatment for ITP: 8 (72.7%), corticosteroids-CS (5), CS and intravenously immunoglobulin-IVIg (3), splenectomy (4), dapsone (1); last median platelet count before pregnancy: 170x109/L (range: 118-363). Platelets count decreased below 100x109/L in 3 pregnancies (27.2%) from the first trimester for one patient, from the second trimester for one other and from the third trimester for the last one, with a nadir of 3, 39 and 87 (x109/L) respectively. One of them experienced a severe bleeding (grade 3 according to the International Working Group bleeding classification). All thrombocytopenic patients required treatment during pregnancy: CS+IVIg for 2 (one for bleeding and one to allow epidural analgesia) and IVIg for the other (to allow epidural analgesia). For these 3 women, the median platelet count at delivery was 128 (range: 38-159) and consequently only 2 of them could have epidural analgesia. No bleeding during delivery was observed. Transient thrombocytopenia occurred in 2 newborns. Primary ITP considered as cured may relapse during pregnancy and may induce severe bleeding requiring specific treatment. A tight monitoring should be proposed to all pregnant women with a history of primary ITP, even after several years of complete remission. Disclosures Récher: Celgene, Sunesis, Amgen, Novartis, Chugai: Membership on an entity's Board of Directors or advisory committees, Research Funding.

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