ITP in pregnancy - Clinicals, Diagnosis, and Management

Obstetrics

Clinicals - History

Fact Explanation
Asymptomatic Pregnant women with ITP can be asymptomatic and maybe diagnosed at routine investigations Asymptomatic
Pregnant women with ITP can be asymptomatic and maybe diagnosed at routine investigations
Easy bruisability, petechiae ( purple-red rash) They may complain of easy bruisabilty in skin following trauma or spontaneously. Also a rash (Petechiae) may also be a complaint. This is due to low platelet count. Easy bruisability, petechiae ( purple-red rash)
They may complain of easy bruisabilty in skin following trauma or spontaneously. Also a rash (Petechiae) may also be a complaint. This is due to low platelet count.
Mucosal bleeding such as epistaxis or gingival bleeding Low platelet count may cause bleeding into mucosal membranes therefore, nasal bleeding, gum bleeding are frequent complaints Mucosal bleeding such as epistaxis or gingival bleeding
Low platelet count may cause bleeding into mucosal membranes therefore, nasal bleeding, gum bleeding are frequent complaints
Menorrhagia prior to pregnancy or post partum hemorrhage in previous deliveries Low platelet count results in mucosal bleeding therefore menorrhagia or previous episodes of post partum hemorrhage can occur Menorrhagia prior to pregnancy or post partum hemorrhage in previous deliveries
Low platelet count results in mucosal bleeding therefore menorrhagia or previous episodes of post partum hemorrhage can occur
Headache, confusion, sudden paralysis of a limb, aphasia Rarely <1% of patients, intra cranial bleeding may occur and these neurological symptoms can occur. Headache, confusion, sudden paralysis of a limb, aphasia
Rarely <1% of patients, intra cranial bleeding may occur and these neurological symptoms can occur.
In the neonate, spontaneous or prolonged bleeding after venipuncture or circumcision This raises suspicion of neonatal thrombocytopenia. The circulating antibodies can cross the placenta and platelet destruction in the baby and subsequent neonatal immune thrombocytopenia In the neonate, spontaneous or prolonged bleeding after venipuncture or circumcision
This raises suspicion of neonatal thrombocytopenia. The circulating antibodies can cross the placenta and platelet destruction in the baby and subsequent neonatal immune thrombocytopenia

Clinicals - Examination

Fact Explanation
Petechiae, Ecchymotic patches Petechiae are small (<3 mm) red or purple spot on the skin, caused by a minor hemorrhage and they do not blanch on pressure and Ecchymotic patches are larger than petechiae and these manifestations are due to low platelet count. Petechiae, Ecchymotic patches
Petechiae are small (<3 mm) red or purple spot on the skin, caused by a minor hemorrhage and they do not blanch on pressure and Ecchymotic patches are larger than petechiae and these manifestations are due to low platelet count.
Gum bleeding Low platelet count may result in bleeding from gums and can be clinically seen Gum bleeding
Low platelet count may result in bleeding from gums and can be clinically seen
Hemorrhagic bullae in the oral cavity Oral lesions could be the initial manifestations and these include petechiae, purpura, ecchymosis, hemorrhagic bullae, and hematoma formation Hemorrhagic bullae in the oral cavity
Oral lesions could be the initial manifestations and these include petechiae, purpura, ecchymosis, hemorrhagic bullae, and hematoma formation
Retinal hemorrhages Low platelet count can also cause bleeding in the retina which can be detected by ophthalmoscope. Retinal hemorrhages
Low platelet count can also cause bleeding in the retina which can be detected by ophthalmoscope.
Pallor Sometimes bleeding may be profuse to cause anemia and clinical pallor Pallor
Sometimes bleeding may be profuse to cause anemia and clinical pallor
In the neonate hypotonia, reduced movements of limbs This raises the suspicion of cerebral hemorrhage due to neonatal thrombocytopenia due to placental crossing of maternal antibodies In the neonate hypotonia, reduced movements of limbs
This raises the suspicion of cerebral hemorrhage due to neonatal thrombocytopenia due to placental crossing of maternal antibodies
In the neonate prolonged bleeding from venepuncture sites, circumsicion site This raises the suspicion bleeding tendency due to neonatal thrombocytopenia due to placental crossing of maternal antibodies In the neonate prolonged bleeding from venepuncture sites, circumsicion site
This raises the suspicion bleeding tendency due to neonatal thrombocytopenia due to placental crossing of maternal antibodies

Investigations - Diagnosis

Fact Explanation
Full blood count Platelet counts are low as well as hemoglobin could be low due to bleeding. White cell count is also important to exclude any infective cause Full blood count
Platelet counts are low as well as hemoglobin could be low due to bleeding. White cell count is also important to exclude any infective cause
Peripheral smear Platelets are normal
to large in size. Red and white blood cells are usually normal in ITP
Peripheral smear
Platelets are normal
to large in size. Red and white blood cells are usually normal in ITP
Antiplatelet antibodies This test is not commonly done but these can be detected in the serum of women with ITP. Antiplatelet antibodies
This test is not commonly done but these can be detected in the serum of women with ITP.
Bone marrow aspiration This may demonstrate increased numbers of megakaryocytes. Usually this is not necessary unless patient is having lymph node enlargement or organomeagly. But this is usually done before splenectomy. Bone marrow aspiration
This may demonstrate increased numbers of megakaryocytes. Usually this is not necessary unless patient is having lymph node enlargement or organomeagly. But this is usually done before splenectomy.
Prothrombin time/activated partial thromboplastin time These tests are done to exclude any coagulation factor deficiencies Prothrombin time/activated partial thromboplastin time
These tests are done to exclude any coagulation factor deficiencies
Hepatitis B and C and HIV serologies Hepatitis B, C and HIV need to be excluded, therefore these tests are done. Hepatitis B and C and HIV serologies
Hepatitis B, C and HIV need to be excluded, therefore these tests are done.
Antinuclear antibody To exclude SLE, this is done Antinuclear antibody
To exclude SLE, this is done
Antiphospholipid antibodies To exclude Antiphospholipid syndrome, this is done Antiphospholipid antibodies
To exclude Antiphospholipid syndrome, this is done
A direct antiglobulin test or Coombs test This is necessary to rule out complicating autoimmune hemolysis (Evans syndrome) A direct antiglobulin test or Coombs test
This is necessary to rule out complicating autoimmune hemolysis (Evans syndrome)
liver functiontests for bilirubin, albumin, total protein, transferases, and alkaline phosphatase To exclude liver disease causing thrombocytopenia liver functiontests for bilirubin, albumin, total protein, transferases, and alkaline phosphatase
To exclude liver disease causing thrombocytopenia
Cord blood of the neonate for full blood count when neonatal thrombocytopenia is suspected, cord blood is checked for platelet count at birth Cord blood of the neonate for full blood count
when neonatal thrombocytopenia is suspected, cord blood is checked for platelet count at birth

Investigations - Management

Fact Explanation
Full blood count To assess the platelet count Full blood count
To assess the platelet count
Fasting blood sugar As the patients are started on steroid therapy, to detect development of diabetes Fasting blood sugar
As the patients are started on steroid therapy, to detect development of diabetes
Full blood count To assess the platelet count, hemoglobin count prior to surgery Full blood count
To assess the platelet count, hemoglobin count prior to surgery
Coagulation studies To exclude any coagulopathy prior to surgery Coagulation studies
To exclude any coagulopathy prior to surgery
Renal function tests- Serum Creatinine, Blood urea nitrogen To exclude any renal dysfunction prior to anesthesia Renal function tests- Serum Creatinine, Blood urea nitrogen
To exclude any renal dysfunction prior to anesthesia
Grouping and Rh Prior to starting anti D immunoglobulin as a treatment in Rh positive mothers Grouping and Rh
Prior to starting anti D immunoglobulin as a treatment in Rh positive mothers
Viral screening ( HIV, hepatitis C virus, and hepatitis B virus) As these virus infections can also produce a similar clinical picture and can cause thrombocytopenia Viral screening ( HIV, hepatitis C virus, and hepatitis B virus)
As these virus infections can also produce a similar clinical picture and can cause thrombocytopenia
Thyroid function tests Anti thyroid antibodies are found to be prevalent in patients with ITP probably due to auto immune nature. Therefore this tests may be done but could be normal Thyroid function tests
Anti thyroid antibodies are found to be prevalent in patients with ITP probably due to auto immune nature. Therefore this tests may be done but could be normal

Management - Supportive

Fact Explanation
Patient education Patient should be educated regarding the nature, course and prognosis of the disease. Also should be reassured that there will be no harm for the baby due to the disease, and should be advised on the importance of follow up and available treatment options. Patient should be educated on warning signs such as headache, paralysis of a limb, aphasia (Features of intracranial hemorrhage)to seek immediate medical attention. Patient education
Patient should be educated regarding the nature, course and prognosis of the disease. Also should be reassured that there will be no harm for the baby due to the disease, and should be advised on the importance of follow up and available treatment options. Patient should be educated on warning signs such as headache, paralysis of a limb, aphasia (Features of intracranial hemorrhage)to seek immediate medical attention.
Follow up No treatment is necessary if platelet counts remain above 50,000/μL and the patient is asymptomatic. Therefore regular follow up of the patient is important with attending to obstetric care. Follow up
No treatment is necessary if platelet counts remain above 50,000/μL and the patient is asymptomatic. Therefore regular follow up of the patient is important with attending to obstetric care.
Activity When there is very low platelet count, any activity which can cause trauma is better avoided Activity
When there is very low platelet count, any activity which can cause trauma is better avoided
Acute management of a life threatening hemorrhage Patient should be resuscitated first with attending to airway, breathing and circulation. Platelet transfusion is carried out in this instance for a rapid response. Acute management of a life threatening hemorrhage
Patient should be resuscitated first with attending to airway, breathing and circulation. Platelet transfusion is carried out in this instance for a rapid response.

Management - Specific

Fact Explanation
Steroid therapy Prednisolone is used as the first line treatment. But treatment is not needed if platelet counts remain above 50,000/μL and the patient is asymptomatic. But even if the patient is having abnormal bleeding, or prior cesarean delivery which is invasive treatment will be carried out. Steroid therapy
Prednisolone is used as the first line treatment. But treatment is not needed if platelet counts remain above 50,000/μL and the patient is asymptomatic. But even if the patient is having abnormal bleeding, or prior cesarean delivery which is invasive treatment will be carried out.
Intravenous immune globulin (IVIG) IV immunoglobulin blocks the attachment of antiplatelet antibodies to platelets and gives a rapid response. especially in instances such as prior to surgery or bleeding. But this is very expensive. Intravenous immune globulin (IVIG)
IV immunoglobulin blocks the attachment of antiplatelet antibodies to platelets and gives a rapid response. especially in instances such as prior to surgery or bleeding. But this is very expensive.
Anti-D immunoglobulin This is for Rh-positive women but still controversial when it comes to use. Anti-D immunoglobulin binds to maternal red blood cells and blocks the Fc receptor. Then there's phagocytosis of these anti D bound red blood cells in the reticulo-endothelial system in the spleen. Anti-D immunoglobulin
This is for Rh-positive women but still controversial when it comes to use. Anti-D immunoglobulin binds to maternal red blood cells and blocks the Fc receptor. Then there's phagocytosis of these anti D bound red blood cells in the reticulo-endothelial system in the spleen.
Azathioprine This is the only immunosuppressive drug used in pregnancy. Vinca alkaloids, androgens, and most immunosuppressive drugs are not recommended in pregnancy. Dapsone, and Danazol are not recommended in pregnancy. Azathioprine
This is the only immunosuppressive drug used in pregnancy. Vinca alkaloids, androgens, and most immunosuppressive drugs are not recommended in pregnancy. Dapsone, and Danazol are not recommended in pregnancy.
Splenectomy Antibody bound platelets are destructed in the spleen. Therefore aplenectomy will help to chieve remission and carried out in first and second trimesters. Prior to splenectomy, immunization against pneumococcus, meningococcus, and Haemophilus influenzae is done. Splenectomy
Antibody bound platelets are destructed in the spleen. Therefore aplenectomy will help to chieve remission and carried out in first and second trimesters. Prior to splenectomy, immunization against pneumococcus, meningococcus, and Haemophilus influenzae is done.
Management of the delivery Vaginal delivery is carried out unless a obstetric reason justifies the C-section. Platelet transfusions, IV Ig might be helpful in the management of delivery. Management of the delivery
Vaginal delivery is carried out unless a obstetric reason justifies the C-section. Platelet transfusions, IV Ig might be helpful in the management of delivery.
Management of neonatal thrombocytopenia cord blood platelet count determined at birth and again at 24 hours in these newborns born to mothers with ITP.
And then repeated daily for the next few days. Any neonates with severe thrombocytopenia (platelets < 30 × 109/l) is treated with IVIG regardless of presence or absence of bleeding.
Management of neonatal thrombocytopenia
cord blood platelet count determined at birth and again at 24 hours in these newborns born to mothers with ITP.
And then repeated daily for the next few days. Any neonates with severe thrombocytopenia (platelets < 30 × 109/l) is treated with IVIG regardless of presence or absence of bleeding.

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