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This document discusses idiopathic thrombocytopenic purpura (ITP) in pregnancy. It defines ITP and provides incidence rates. It describes the immunology and pathophysiology of ITP involving autoantibodies against platelets. The diagnostic approach is outlined including patient history, physical exam, lab tests, and differential diagnosis. Management during pregnancy is discussed focusing on monitoring platelet counts and treatments such as corticosteroids, IVIG, and splenectomy if needed. Management of delivery focuses on achieving sufficient maternal platelet counts for delivery while minimizing fetal risks.
This document discusses idiopathic thrombocytopenic purpura (ITP) in pregnancy. It defines ITP and provides incidence rates. It describes the immunology and pathophysiology of ITP involving autoantibodies against platelets. The diagnostic approach is outlined including patient history, physical exam, lab tests, and differential diagnosis. Management during pregnancy is discussed focusing on monitoring platelet counts and treatments such as corticosteroids, IVIG, and splenectomy if needed. Management of delivery focuses on achieving sufficient maternal platelet counts for delivery while minimizing fetal risks.
This document discusses idiopathic thrombocytopenic purpura (ITP) in pregnancy. It defines ITP and provides incidence rates. It describes the immunology and pathophysiology of ITP involving autoantibodies against platelets. The diagnostic approach is outlined including patient history, physical exam, lab tests, and differential diagnosis. Management during pregnancy is discussed focusing on monitoring platelet counts and treatments such as corticosteroids, IVIG, and splenectomy if needed. Management of delivery focuses on achieving sufficient maternal platelet counts for delivery while minimizing fetal risks.
(ACOG), ITP : (1) persistent thrombocytopenia (platelet count < 100×109/L with or without megakaryocytes in peripheral smear), (2) normal or increased medullary megakaryocytes,(3) exclusion of other systematic diseases or drugs that are associated with thrombocytopenia, and (4) absence of splenomegaly
Ben S et al. Obstetrics and Gynecology International Volume 2010
INSIDENCE
Approximately 200.000 individuals in the
USA have ITP. Helsinski, 1,8:1000 labor Thrombocytopenia has been observed in 7 to 10 percent of all pregnancies.
Thrombocytopenia at delivery: a prospective survey of 6715 deliveries. Am J Obstet Gynecol and
Platelet Disorders Support Asociation. This shows the Incidence of the types of Thrombocytopenic Purpura during Pregnancy Thrombocytopenia in Pregnancy (n=15,000) Gestational Thrombocytopenia 74% Hypertension in pregnancy (PET) 21% Immune (Allo-Immune thrombocytopenia) 4% Other 1%
Burrows RF, Kelton JG.
Low fetal risks in pregnancies associated with idiopathic thrombocytopenic purpura. Am J Obstet Gynecol. IMUNOLOGY AND PATHOPHYSIOLOGY Chronic Idiopathic Thrombositopenic Purpura. The New England Journal Medicine Vol.331 No.18. Molecular mimicry DIAGNOSTIC APPROACH
ITP diagnosis is of exclusion
Thrombocytopenia can be caused by myriad conditions including systemic disease, infection, drugs, and primary hematologic disorders An increased risk of ITP is also associated with measles-mumps-rubella vaccination Patient History
Symptoms, type, severity, and duration of
bleeding Hemostasis with prior surgeries or pregnancies Weight loss, fever, and headache Symptoms of autoimmune disorders (atrhralgias, skrin rash) Risk factor for HIV infection Pregnancy status Medication Transfussion history Physical examination
Signs, type, and severity of bleeding
Liver, spleen, and lymph node, jaundice Evidance of infection (HIV) Evidance of autoimmune disease (athritis, goiter, nephritis) Evidance of thrombosis Neurologic function Skeletal anomalies Peripheral blood count Evaluation of peripheral blood smear Bone marrow examination Helicobacter pylori testing HIV and HCV testing Quantitative immunoglobulin level testing Direct antiglobulin test Blood group Rh(D) typing DIFFERENTIAL DIAGNOSIS MANAGEMENT Maternal management during gestation (Immune Thrombocytopenia in Pregnancy. Hematol Oncol Clin North Am. 2009 )
collaboration between the obstetrician and
hematologist. should be seen monthly in the first and second trimester, every 2 weeks after 28 weeks, and weekly after 36 weeks. blood pressure, weight, urine dipstick analysis for protein, and serial platelet counts. Treatment has been recommended for women with a platelet count below 10,000/μl at any time during pregnancy, or below 30,000/μl in the second or third trimester or when associated with bleeding 1st line prednisone is 1 mg/kg/day (based on the pre-pregnancy weight) therapy is indicated but not urgent 20-30 mg/day of prednisone intravenous immunoglobulin (IVIg) first line agent for severe thrombocytopenia, or thrombocytopenic bleeding in 3th trimester 2 gm/kg over 2-5 days) intravenous immunoglobulin (IVIg) is an effective means of raising the platelet count rapidly Splenectomy may be considered as another option for patients who fail to adequately respond to corticosteroids or IVIg In patients who develop severe ITP refractory to steroids and IVIG, and who are beyond the optimal second trimester window for splenectomy, intravenous anti-D has been used successfully. cytotoxic and immunosuppressive agents, not used in pregnancy Management of parturition: fetal and maternal considerations
the primary consideration is achieving a
platelet count sufficient to minimize maternal hemorrhage Maternal platelet count of 50,000/μl is sufficient for vaginal delivery as well as cesarean section. The most feared consequence of fetal thrombocytopenia is the risk of intracranial hemorrhage, There was no correlation between platelet counts or the ITP status of the mothers and the development of neonatal thrombocytopenia no association of intracranial hemorrhage with the mode of delivery cesarean section be performed solely for maternal indications. THANK YOU
Low-Molecular-Weight Heparin Added To Aspirin in The Prevention of Recurrent Early-Onset Pre-Eclampsia in Women With Inheritable Thrombophilia: The FRUIT-RCT