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2013 Thrombocytopenia Pocket Guide PDF
2013 Thrombocytopenia Pocket Guide PDF
2013 Clinical
Practice Guide on
Thrombocytopenia in
Pregnancy
2013 Clinical
Practice Guide on
Thrombocytopenia
in Pregnancy
Presented by the American
of Hematology
Presented bySociety
the American
Anita Rajasekhar, MD, MS
Society of Hematology
Terry Gernsheimer, MD
Anita Rajasekhar,
MD,
MSMD, PhD
Roberto
Stasi,
Andra H.MD
James, MD, MPH
Terry Gernsheimer,
Roberto Stasi, MD, PhD
Andra H. James, MD, MPH
I.
Not pregnancy-specific
Severe preeclampsia
(15-20%)
HELLP syndrome
(<1%)
AFLP (<1%)
TTP/HUS **
Systemic lupus erythematosus **
Antiphospholipid syndrome **
Viral infections **
Bone marrow disorders **
Nutritional deficiency **
Splenic sequestration (liver
diseases, portal vein thrombosis,
storage disease, etc) **
Thyroid disorders **
Antiphospholipid antibodies
Anti-nuclear antibody (ANA)
Thyroid function tests
H. pylori testing
DIC testingprothrombin time (PT), partial thromboplastin
time (PTT), fibrinogen, fibrin split products
VWD type IIB testing*
Direct antiglobulin (Coombs) test^
Quantitative immunoglobulins
Relatively contraindicated
Reference: Adapted from Gernsheimer T, James AH, Stasi R, How I treat thrombocytopenia in pregnancy. Blood. 2013;121(1):38-47.
For a woman whose platelet count is < 80 x 109 but has not required
therapy during pregnancy, oral prednisone (or prednisolone) can be started
10 days prior to anticipated delivery at a dose of 10-20 mg daily and titrated
as necessary.
Given the difficulty predicting severe thrombocytopenia in neonates and
the very low risk of intracranial hemorrhage (<1.5%) or mortality (<1%),
the mode of delivery should be determined by obstetric indications.
Percutaneous umbilical blood sampling (PUBS) or fetal scalp blood
sampling is not helpful in predicting neonatal thrombocytopenia, is
potentially harmful, and is, therefore, not recommended.
The infant nadir platelet count occurs 2-5 days after delivery and a
spontaneous rise occurs by day 7.
Women with ITP are at an increased risk of venous thromboembolism, and
some form of postpartum thromboprophylaxis should be considered.
B. HELLP Syndrome
HELLP syndrome, which affects 0.6% of pregnant women, is a variant
of preeclampsia. However, in 15-20% of cases of HELLP syndrome, no
hypertension or proteinuria is present. 70% of cases occur in the late second
or third trimester; the remainder occur postpartum.
Criteria for AFLP from case series and expert opinion were used in a
prospective study from Southwest Wales (the Swansea Criteria) and have
subsequently been used in other studies. Six or more of these criteria in
the absence of another explanation were required for a diagnosis of AFLP.
Leukocytosis
Abdominal pain
Polydipsia/polyuria
Elevated transaminases
Encephalopathy
Elevated ammonia
Elevated bilirubin
Renal impairment
Hypoglycemia
Coagulopathy
Reference: Knight M, Nelson-Piercy C, Kurinczuk JJ, Spark P, Brocklehurst P. A prospective national study of acute fatty liver of pregnancy in the UK. Gut. 2008;57(7):951-956.
Sibai Criteria1993
Martin Criteria1991
Reference: adapted from Sibai BM, Ramadan MK, Usta I, Salama M, Mercer BM,
Friedman SA. Maternal morbidity and mortality in 442 pregnancies with hemolysis,
elevated liver enzymes, and low platelets (HELLP syndrome). Am J Obstet Gynecol.
1993;169(4):1000-1006.
InciDiagnostic
dence Features
During
Pregnancy
(%)
Laboratory Clinical
PathoFindings Symptoms physioland Physi- ogy
cal Exam
Comments
Gestational 5-9
thrombocytopenia
Typically
normal
Unclear
Diagnosis of
exclusion
Resolution of
thrombocytopenia postpartum
No fetal thrombocytopenia
ITP
Onset any
trimester
Thrombocytopenia
outside of
pregnancy
possible
May have
signs of
bleeding,
bruising,
petechiae
Antibody
induced peripheral PLT
destruction
Decreased
thrombopoiesis
Diagnosis of
exclusion
May be associated with fetal
thrombocytopenia
<1
PLT <100
x 109
+/- large
PLT on PBS
Disease
InciDiagnostic
dence Features
During
Pregnancy
(%)
Laboratory Clinical
PathoFindings Symptoms physioland Physi- ogy
cal Exam
Comments
Preeclamp- 5-8
sia
Systolic BP
140mmHg
or diastolic
BP
90mmHg
Systemic
endothelial
dysfunction
Inadequate
placentation
HELLP
syndrome
<1
70% onset in
late second or
third trimester
30% onset
postpartum
MAHA
Elevated
LFTs
Elevated
LDH
Any or all
signs of
preeclampsia may be
present
15-20%
of cases
no HTN or
proteinuria is
present
Systemic
Variant of
endothelial preeclampsia
dysfunction
Inadequate
placentation
AFLP
<0.01
Onset third
trimester
PLT>50 x
109
Elevated
LFTs, CR,
WBC, uric
acid,
ammonia
Prolonged
PT/PTT,
decreased
fibrinogen
Hypoglycemia
On the
spectrum
with preeclampsia
MAHA not
characteristic
Conjugated bilirubin frequently
>5mg/dL
Liver dysfunction more
significant than
in HELLP/preeclampsia
Onset any
trimester, but
more common
during third
trimester or
post partum
MAHA
Elevated
CR
Schistocytes on
PBS
Fever
Abdominal
pain
Nausea/
vomiting
Headache
Visual
changes
Altered mental status
Congenital
deficiency /
inhibitor of
ADAMTS13
(TTP)
Complement dysregulation
(aHUS)
ADAMTS13
activity
<5% in TTP
LFT and BP
usually normal
TTP/aHUS <0.01
Thrombocytopenia may
precede other
manifestations
of preeclampsia
Can present
postpartum
Abbreviations:
PLT = platelet
PBS = peripheral blood smear
BP = blood pressure
MAHA = microangiopathic
hemolytic anemia
CR = creatinine