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MRCOG PART 2 SBAs and EMQs

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Essay 326: Thrombocytopaenia

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		Posted by MR R. Thu Jul 8, 2010 09:37 pm
MR A healthy 23 year old woman has been referred to the antenatal clinic at 29 weeks gestation. FBC performed at 28 weeks showed Hb = 11.5g/dl, white cell count = 8.5 x 109/L and a platelet count of 65 x 109/L. (a) Discuss your antenatal management [13 marks]. Idiopathic thrombocytopenia is a diagnosis of exclusion and the platelets fall below 100 x 10-9.Gestational thrombocytopenia is associated with gradual fall in platelets usually starting in the 2 nd or 3rd trimester and rarely fall below 100x10-9.I will take history of any excessive bruising,petechialhaemorrhages,frequent epistaxis or gum bleeding.I will ask her regarding previous history of menorrhagia or bleeding into joints.I will ask if she suffered from any immunologically mediated diseases like immune thrombocytopenia,Rhuematoid arthritis or systemic lupus erythematosus.I will gather if she received any treatments with steroids/immunoglobulins which may suggest immune mediated throbocytopenia.I will ask if there is any family history of such immune mediated diseases.I will check ifshe is currently on medication which can bring her platelets down.I will gather if she suffered from recent viral infections which can cause thrombocytopenia.I will aske for history of headaches,epigastric pain,edema and bluured vision which can suggest underlying preeclamsia.I will examine her for signs of bruising/petechail haemorrhages over the skin. I will review her notes to check her Full bllod count(FBC) results at the time of booking.This will reveal if there was preexisting thrombocytopenia.I will do FBC - to check platelets as this could be an erroneous reading from the labs.This will also helo to rule out pancytopenia.I will check for peripheral smear to check if there is any platelet clumping.I will check bloods for preeclamsia /HELLP syndrome which will inlcude Urea and electrolytes,Liver function tests(increased).I will check clotting studies to identify if any clotting abnormality.I will check bloods for antibody mediated platelet destruction.However this is not specific and Idiopathic thrombocytopenia is a diagnosis of exclusion.Rarely Bone marrow testing is required if reistant to treatment and if there is pancytopenia. I will explain that her platelets are lower than the normal pregnancy ranges. Majority of the pregnancies are uncomplicated.This patient should manged in a multidisciplinary team involving Obsterician(maternal medicine) & Haematologist.The maternal risks include bleeding and haemorrhage if thrmbocytopenia worsens.There is also 4% chance of the fetus being affected.She should have FBC, clotting studies done every 2 - 4 weeks and reviwed in the clinic.Oral steroids(prednisolone) in the dose 5- 10 mg daily can be commenced and increased to a maximum of 40 mg OD.The fetus should be monitored for growth and liquor volume bcos of the risk of IUGR if on steroids.If there is no response to steroids IV Immunoglobulins based on her booking weight is commenced.Very rarely resistent cases might need splenctomy and best done in 2 nd trimester.If this is performed patient should be on antibiotics and get pnemococcal vaccine to lower the risk of infection.The plan of delivery will be in an consultant unit.I will document all the plans and follow up in the notes (b) She presents in labour at 38 weeks gestation. Discuss your intra-partum care [7 marks]. I will establish an IV access and take bloods for FBC & clotting studies and cross match blood( 2- 4 units).I will review her recent results.I will inform anasethetist to decide about regional anaesthesia.The haemotologist oncall will be contacted if platelets are < 50 x 10 -9.If the patient has been on steroids I will commence IV Hydrocortisone to prevent collapse from addisonian crisis.Continious monitoring of the fetus is done.I will avoid Fetal scalp electrode,fetal blood sampling and traumatic deliveries bcos of the risk of fetal thrombocytopenia (intracranial haemorrhage).I will manage third stage actively with oxytocin /syntometrine according to hospital policy tp prevent postpartum haemorrhage.Caesarean section is reserved only for obstetric indication.Platelet transfusion is reserved only for severe cases after liasion with haemotologist( < 30 x10 - 9 for SVD & < 50 x 10 -9 for CS).Neonatal staff will be informed at deliver and cord blood obtained to ckech platelets .Avoid IM vitamin K.
		Posted by Kiran J. Thu Jul 8, 2010 11:42 pm
a:It is important to establish a cause of her thrombocytopenia.Immune thrombocytopenia constitutes 3% of pregnanct women with thrombocytopenia whereas 70 % are due to pregnancy associated thrombocytopenia but the platelet count is usually >70 or 100.Antenatal management constitutes history of mucocutaneous bleeding, epistaxis,bleeding into joints, spontaneous bruising and swollen tender joints.Also if there has been any history of ITP in the past .Immunological conditions such as Antiphospholopid antibody syndrome ,SLE ,rheuamatide arthritis.Any history of mennorhagia neccitating hospital addmission and blood or platelet transfusion.History of viral infections and any in the recent past.Important to enquire about drugs such as Heparin,rifampcine,quinine or trimethoprim.If she is a multigravida she should be asked if there is history of thrombocytopenia in her last pregnancies, if the children have history of thrombocytopenia or platelet transfusion. She should be examined for s/o liver disease ie Jaundice, spider neavi and ascites,petechial haemorhage and bruises.Check blood pressure,epigastric tendernedd, urine dipstick clonus and reflexes to rule out pre-eclampsia Her antenatal management needs multidisciplinary care with obstetrician with speciel interest in Haematology, Haematologist, haematology specielist nurse, Anaesthetist. She should have her bloods repeated to rule out platelet clumping and hence an FBC in K citrate rather than EDTA is sent.A clotting profile ,Liver function tests,renal function tests , urine PCR if indictaed, hepatitis profile (if indicated by history and examination) antiphospholopid antibodies and anti cardiolipin antibodies.She should be councelled that as long shei s asymptomatic majority of women wont need any treatment antenatally but may require tratment before delivery to optimize platelet levels at least above 50 and reduse risk of haemmorhage.Close Liason with haematologist,serial platelets (2-4 weekly) ,and consider oral prednisilone in case platelets fall below 70.The oral regime of prednisilone can start at 20 mg?day and increment to 60 if no response seen in a week.Thereafter if platelets level improve low dose prednisilone can continue.if the platelets fall very low or there is haemorhage or if the thrombocytopenia is refractory to managemenrt IVIG can be considered.It is given as a day case in haemtology ward and oserved for s/o anaphylaxis.To rhesus positive womenAnti D Immune globulin can be given(Efficacy similar to IVIG in rhesus + women.) In very rare cases when a patient is refractory to medical management then splenectomy or platelet transfusion has also been given . Induction of labour for obstetric indications but can be done if platelet levels are<50and patient is given steroids or IVIG to raise them as this level is safe for vaginal delivery. b Intrapartum management constitutes maternal and fetal considerations. Maternal considerations are her recent platelet levels and they should be above a 50 to reduce risk of haemmorhage. As for epidural analgesia.Anaesthetic review early in labour and generally epidural is avoided at platelets below 80 as there is risk of bleeding and spinal compression. Syntometrine at 3rd stage and active managemento watch for pph.Haematologist aware of addmission in labour and platelets given after thier advice if platelets fall below 20. Fetal considerations are avoidance of FBC,Inavasive monitoring with FSE and traumatic midcavity or ventouse delivery.Neonatologist to be informed. Take cord bloods for neonates platelet count and if low consider a cappillary platelet level and repeat on day 4 if low.If platelet levels are normal no further tests required. Avoid I/M vit K(can have oral).Rarely the baby may have thrombocytopenia and may need cranial dopplers and platelet transfusion/IVIG .
		Posted by H H. Fri Jul 9, 2010 03:49 am
hhh This patient antenatal care should be via multidisciplinary team which include consultant obstetrician, midwife, neonatologist and hematologist knowing that the causes could be gestational thrombocytopenia, pre eclampsia with or without HELP,auto immune(iso immune) ,bone marrow depression by drugs,chemotherapy or radiation.. Patient history is taken including, history of bleeding tendency, previous post partum hemorrhage , previous treatment of thrombocytopeenia, previous chemotherapy ,previous splenectomy or previous platelet transfusion. Her pulse, BP (pre eclampsia) and temp taken. Abdominal examination for fundal level and lie and skin manifestations of thrombocytopenia, hemorrhgic spots. Review of her previous antenatal care before 29wk, dating scan, anomaly scan, blood tests performed,screening tests. Blood born infections due to previous transfusions are noticed and performed if not done previously. More frequent antenatal visits ,with monitoring of platelet counts in liaison with hemalogist to keep it above 50x10 9/l by platelet transfusion or antiplatelet immunoglobulins if needed.This is more important towards the end of pregnancy to guard against post partum hemorrhage . Keeping platelet count above 80x10 9/l would allow regional analgesia to be given safely during labour. Repeated fetal brain imaging to detect fetal intraventricular hemorrage due to fetal thrombocytopenia, however this is unlikely to occur with iso immune thrombocytopenia as compared with allo immune thrombocytopenia which causes fetal thrombocytopenia,but here maternal platelet is normal Fetal thrombocytopenia is difficult to diagnose and tertiary center which can offer cordocentesis,fetal sampling and even platelet transfusion. Proper management of pre eclampsia and HELP syndrome if develops ,controlling BP, mag sulphate , stabilisation of patient,SCPU help and early delivery, post partum care. Would provide written information. Intrapartum care should be a team work involving the obstetrician,anaesthetist,hematologist ,midwife and neonatologist.Platelet count should be kept above 80x10 9/l ,if regional analgesia required. Continuous electronic fetal monitoring is needed if there is fresh bleeding,meconium stained liquor,oxytocin augmentation,putting regional analgesia, pyrexia ,abnormal fetal heart or maternal wishes. Application of big bore IV line for IV fluids in case patient need emergency intervention. local vaginal examination every 2-4 hr for progress. Avoidance of fetal scalp electrodes,fetal blood sampling or instrumental delivery as fetus may have thrombocytopenia. Active management of 3rd stage of labour to reduce post partum hemorrhge. Cesarean section for obstetric indication, but need to be done or under observation of consultant obstetrician .
		Posted by nazia M. Fri Jul 9, 2010 03:58 am
Take history to establish the diagnosis of thrombocytopenia ask about bleeding from any sites like menorrhagia,gum bleeding,hematemesis,bruises,petechial hemorrhage,if multigravida previous any postpartum hemorrhage.whether she is having any renal and liver disorders,ask about previous obstetrical history like recurrent miscarriage,IUGR,abruptio placentae IUD to exclude autoimmune disease(SLE,antiphospholipid syndrome)whether she is taking any drugs(heparin,chemotherapy),any viral illness(HIV,CMV,EBV),history of peeclampsia,hellp syndrome,acute fatty liver.Gestational thrombocytopenia is diagnosis of exclusion of disease occur towards the end of pregnancy and platelet rarely fall below 100x109 platelet comes back normal after delivery.if there is no cause immune thrombocytopenic purpura can be considered.investigations include;blood film for platelet clumps and microangiopathic hemolytic anemia,clotting screening,renal and liver function test,antiphospholipid antibodies,anti nuclear antibodies,viral screen.Patient should be manage in colloboration with hemotologist serial monitoring with platelet count spontanous bleeding donot occur if platelet >2ox109 Patient should be treated if count<50x109.oral steriod should be given response rate 70-80% serum glucose monitoring should be considered if noresponse ivigG should be given but needs hospital admission.if above treatment failed splenectomy preferably in 2nd trimaster can be considered otherwise avoided.secondary treatment are high dose methylprednisolone,azathioprine or plasma exchange.Patient should be properly counselled about the conditon to make informed decision. b)Patient antenatal record reviewed taking any treatment or not recent platelet count .experienced obstetrician,hematologist,anaesthetist and paeditrician should be involved in management.if platelet count >50x109 spontaneous vaginal delivery or caesarean section can take place and regional anaesthesia can be used if count>80x109.fetal thombrocytopenia can not be predicted by maternal condition.Fetal blood sampling,fetal scalp electrode,vontouse and rotational forcep should be avoided.Caesarean section should be done for only obstetric indication if patient is on steriod therapy then consider iv hydrocortisone for adrenal crisis.fetal cord blood should be sent for platelet count nadir in 24-48hr so monitor count.Patient is given support and encourgement.
		Posted by Bee N. Fri Jul 9, 2010 04:40 am
A healthy 23 year old woman has been referred to the antenatal clinic at 29 weeks gestation. FBC performed at 28 weeks showed Hb = 11.5g/dl, white cell count = 8.5 x 109/L and a platelet count of 65 x 109/L. (a) Discuss your antenatal management [13 marks]. (b) She presents in labour at 38 weeks gestation. Discuss your intra-partum care [7 marks] (BEE) A) I will review her booking blood investigations to find out if the low platelet is of recent onset(Gestational thrombocytopaenia usually gets worse in 2nd to 3rd trimester). I will take history to explore the diffrentials. History of headache, epigastric pain, visual symptoms suggest pre eclampsia. History of jaundice suggests HELLP syndrome. Recent flu like illness suggest recent viral infection such as CMV as a cause. Idiopathic thrombocytopaenic purpura usually occurs before pregnancy but may occur in pregnancy and is usually a diagnosis of exclusion. I will ask for parity and presence of similar illness in previous pregnancies(gestational). I will ask for family history of low platelets ( ITP or constitutional). Patient unlikely to be on any drug causing low platelets if healthy. I will start examination by checking for jaundice taking her BP ( hypertensive disorders). I will do afull neurological examination checking for reflexes (hyperreflexia in pre eclampsia). There may be varied neurological findings in thrombotic thrombocytopaenis purpura (TTP). I will take urine for urinalysis (protienuria in pre eclampsia). I will take blood for FBC( ? deteriorating platelet, low Hb-hemolysis), LFT( elevated in hypertensive disorders), U&E ( may be abnormal in hypertensive disorders or microangiopathy such as heamolitic uraemic syndrome. I will also check for lactate dehydrogenase if hemolysis is suspected as in HELLP or microangiopathies. Patient should be managed in a multidisciplinary setting involving the obstetrician, hematologist, paediatrician, anaesthetist and specialist midwife. She should be seen at least every 2 weeks in a combined hematology/Obstetrics clinic. Investigations should however be repeated at least weekly. Patient who are placed on steroids should be assessed for gestatational diabetes and UTI and asked to report any bleeding episode or abdominal pain in case of abruption. I will also consider referral to fetal medicine unit if ITP which can affect the fetus if suspected. The aim of antenatal management is to optimise platelet level prior to delivery. If HELLP or severe pre eclamsia is diagnosed, immediate delivery after stabolisation is adviced. Other causes of low platelets do not necessarily require immediate delivery. Platelets are to be kept above 50x109/L for delivery. Anaesthetic review to discuss analgesia before term is important as some anaesthetist will not give epidural if platelet is less that 80x 109/L. Prednisolone is usually the first line of treatment for gestational thrombocytopaenia or ITP. Gestational thrombocytopaenia rarely results in platelets less than 70 and ofetn resolves afetr delivery. However, both gestational thrombocytopaenia and ITP are diagnosis of exclusion. Other modes of traetment that can be considered for ITP is immunoglobulin therapy, anti D in those rhesus positive, splenectomy and platelet transfusion in severe cases. There should be a clear documentation of treatment and care plan. Delivery can be planned to ensure the presence of all medical personnel needed. Ceasrean section would be for Obstetric indications. B) When the patient comes in labour, I will take bloods for FBC to check for platelets and Hb level and group/save. An intravenous cannula must be sited in readiness for possible blleding. I will inform the anaesthetist to assess for appropriate analgesia. I will inform the paediatricians who may want to take the baby to the neonatal unit for further investigations after delivery and should be present at delivery. I will commence a continous CTG to pick up any fetal distress as is the case of abruption which is more likely. I will consider platelet transfusion if platelet is less than 50. I will cover labour with intravenous steroids (hydrocortisone 100mg 6 hourly) if patient was given steroids for more than 2-3 weeks preceding their presentation in labour. Durinf delivery I will try to avoid the use of fetal scalp electrode, fetal blood sampling and delivery by high or mid cavity forceps/ ventouse is ITP is suspected. Caesarean section would be for obstetric reasons. Third stage of labour will be managed actively. Cord blood will be taken at delivery to check for platelet levels in the neonate and this will be followed by capillary blood for confirmation if found to be low. If capillary blood is low, platelet levels are reapeat at day 1 and 4.
		Posted by A- N. Fri Jul 9, 2010 05:26 am
A) I would book her under consultant led care, management by multidisiplinary team including obstetrician, haematologist, anaesthetist. I would exclude the other causes of thrombocytopenea as preeclampsia, drug induced, immunological causes, infection, gestational thrombocytopenea is most common cause. I would check the platelet count regularly every 2-4 weekly to ensure the platelet count is above 50x 10^9 as the tendency to bleed after vaginal delivery increases thereafter. Anaesthetic review early so as to have a plan of care for analgesea in labour and if required anaesthetic. plan of care is to be clearly documented. Risks of fetal thrombocytopenea is rare, risks are increased if previous history of splenectomy or platelet count is less than 50X10^9/L. steroids may be needed if platelet count falls below 50X10^9/L after liasing with haematologist. If platelet count is decreasing in spite of steroids, then immunoglobulins are needed. Rarely splenectomy and platelet transfusion is done. Neonatalogist is to be informed so that the newborn is reviewed by neonatal team after delivery. B) intrapartum care Patients with thrombocytopenea is at risk of bleeding. when presenting in labour, I would review the notes with particularly attention to any antenatal care plan. I shall then assess the patient to confirm that she is in active labour, to check for presentation, lie, attitude, frequency and streangth of contractions, vaginal examination for cervical dialation, station, status of membranes, position. I shall ask for CTG to assess the fetal well being. I shall then insert a widebore canulae and request for full blood count so as to get an estemate of haemoglobin status and platelet count. I shall then liase with the anaesthetist to diasuss the options of analgesea especially weather epidural is feasable. Epidural and spinal anaesthesia is contraindicated if platelet count is less than 80X 10^9/L. I shall also request for group and save serum if blood transfusion is required. I shall liase with haematologist and seek advise regarding management especially if platelet transfusion is required. As the patient is high risk, I shall inform the consultant on call about the admission. The patient will be offered adequate analgesia, regular assessment for progress of labour. I shall avoid fetal scalp electrode, fetal blood sampling to assess fetal well being. I shall also avoid difficult forceps especially mid cavity forceps, ventouse delivery as this increases the risk of fetal scalp haematoma and intracraneal bleeds. Immediately after delivery cord blood is checked for platelet count and this is also assessed on day 1 and day 4. Immunoglobulin or platelet transfusion may be required if platelet count is less than 20-40x10^9/L. I would recomend oral viatamin K to neonate rather than intramuscular Vitamin K as intramuscular injection will increase the risk of haematoma. I shall check the maternal platelet count in 6 weeks to confirm that it has come to normal levels which it does in gestational thrombocytopenea, if the platelet counts are still low then I shall refer her to haematologist. I would also offer her contraceptive advise and arrange for preconceptional counselling for next time she plans to get pregnant as reccurrence is known.
		Posted by Aruna R. Fri Jul 9, 2010 08:03 am
A healthy 23 year old woman has been referred to the antenatal clinic at 29 weeks gestation. FBC performed at 28 weeks showed Hb = 11.5g/dl, white cell count = 8.5 x 109/L and a platelet count of 65 x 109/L. (a) Discuss your antenatal management [13 marks]. (b) She presents in labour at 38 weeks gestation. Discuss your intra-partum care [7 marks]. The probable diagnosis is idiopathic thrombocytopenic purpura. Antenatal management: I will elicit history to assess the severity of symptoms like purpuric patches in the skin, gum, nasal bleeding. Since she is healthy now other causes of thrombocytopenia like hypertensive diseases, viral infections and microangiopathies are not present .I will confirm this from history as well as from her hospital records.I will also ask her weather she is on any medications like heparin, rifampicin, trimethoprim or quinine which can cause thrombocytopenia. I will examine her to rule out purpuric spots and other evidence of bleeding. I will repeat the blood tests like full blood count to confirm the diagnosis. After confirming the diagnosis, I will explain it to the patient .I will tell the maternal risks (Usually no risks, rarely cause bleeding gums, postpartum haemorrhage). Fetal risks fetal /neonatal thrombocytopenia.I will also tell her that there is no specific tests to confirm it. Estimation of platelet antibodies is not useful because it has low sensitivity and specificity. Management in a consultant led unit with the multidisciplinary team, which includes obstetrician, haematologist, anaesthetist and neonatologist. Usually will not cause any symptoms. Regular monitoring of the blood levels is essential. If the platelet level drops <20 x 109/l, treatment with oral prednisolone 20 mg/day is offered. I will repeat the platelet count in a week’s time. If it is not improving increasing the dose to 60mg/day till the optimum platelet level obtained, then I will gradually reduce the dose.The other alternatives are intravenous immunoglobulin, spleenectomy and platelet transfusion. Spleenectomy in pregnancy is usually avoided. Intrapartum care : Maternal consideration :I will review her notes to find out the management plan made by the multidisciplinary team and the recent platelet count. I will inform the obstetric consultant and anaesthetist on call. I will establish intravenous access and send bloods for full blood count including platelet count ,group and save. Haematologist and the lab should be informed if the counts are low.The platelet count of >40x 109/l is essential for vaginal delivery >50x109/l for instrumental delivery and 80x109/l for epidural. Supportive care by one to one midwife. Neonatal Consideration: platelet antibodies can cross the placenta and cause fetal thrombocytopenia, which can cause intracranial haemorrhage. This is unpredictable. Sample should be taken from Cord blood, on the 1st and 4th day to check the platelet level. Vitamin K intramuscular injection should be avoided. Delivery considerations; continuous cardiotocography (CTG) monitoring of fetal heart is important.Fetal blood sampling ,fetal scalp eletrode and instrumental delivery especially ventous are avoided. Caesarean section for obstetric indication.Active management of third stage of labour to prevent post partum haemorrhage.
		Posted by karim C. Fri Jul 9, 2010 08:07 am
a)The diagnosis may be gestational thrombocytopenia or autoimmune idiopathic thrombocytopenia. It is difficult to distinguish between the two as antiplatelet antibodies are present in gestational thrombocytopenia and the absence of anti platelet antibodies does not exclude autoimmune thrombocytopenia. Idiopathic thrombocytopenia is a diagnosis of exclusion and possible causes such as viral infection, PET, should be excluded. History is taken about viral infection, , bruising, mucosal bleeding and menorrhagia. If she is a parous woman, enquiry is made about haemorrhage during previous pregnancies or after deliveries, neonatal haemorrhage and history of platelet transfusions as gestational thrombocytopenia is recurrent. Examination is undertaken to detect hypertension, purpura, bruising, and liver enlargement apart from obstetric assessment. Investigations include repeat count and peripheral blood film to exclude platelet clumps there by ruling out spurious thrombocytopenia,U&E, liver function tests, coagulation screen urine dipstix for protein, as PET and HELLP syndrome are associated with thrombocytopenia. The maternal risk includes haemorrhage due to thrombocytopenia. Fetal risks are thrombocytopenia as IgG antibodies cross placenta and may cause fetal or neonatal intracranial haemorrhage whose incidence is about 2% The aim of the management is to maintain adequate platelet counts to minimize the risk of maternal haemorrhage duing pregnancy, delivery and post partum. She should be managed in a unit under care of obstetrician experienced in treating such conditions and close liaison with hematologist is required. Close monitoring of platelet counts is done every fortnightly. The frequency of platelet moitoring is based on the rate of decline. The first line of treatment is with corticosteroids Prednisolone is given at high doses ( 60-80mg/day) until a response is obtained within 4 wks. This should be tapered gradually. The risks of corticosteroid treatments are excessive weight gain, gestational diabetes and psychological problem. If she does not respond to steroids or if the maintenance dose of steroids is high, intravenous immunoglobulin is given in doses of 0.4 mg/kg/day over 5 days. The response is rapid within 24 -48hours. Associated with small risk of transmission of infection and allergic reaction. Splenectomy is usually avoided during pregnancy but she may require in rare situations if she doesn’t respond to steroid and immunoglobulin treatment. This is associated with risk of preterm labour. Nearing term consultation with Obstetric anaesthetist is arranged to discuss about regional analgesia and alternative such as patient controlled analgesia. b)Intrapartum management should be undertaken by multidisciplinary team which includes Obstetrician, haemotologist, anaesthetist and neonatologist. Platelet count of 50-80x 10 9/Lwarrants treatment with platelet transfusions inorder to facilitate epidural analgesia which is not safer with counts below 80x 10 9/L. Monitoring by fetal scalp electrodes and fetal blood sampling is avoided due to the risk of fetal haemorrhage. Traumatic deliveries by ventose application and midcavity forceps are avoided. Aimed for vaginal delivery. And caesarean section is for obstetric reasons only.
		Posted by L S. Fri Jul 9, 2010 08:24 am
LS: (a) Discuss your antenatal management [13 marks]. I would first rule out possible differentials for the cause of her low platelet. The differentials are HELLP syndrome, antiphospholipid syndrome (APLS) or systemic lupus erythematosus (SLE), acute fatty liver, disseminated intravascular coagulation (DIVC), thrombotic thrombocytopenic purpura (TTP), pregnancy associated thrombocytopenia or idiopathic immune thrombocytopenic purpura (ITP) which is a diagnosis of exclusion. Detail history on symptoms of pre eclampsia like headache, blurring of vision, epigastric tenderness are enquired. History of recent flu like illness and drug history asked. Family history of similar condition explored. Risk of low platelet like bleeding tendency and easy bruising asked. Her antenatal records check on booking blood pressure and current blood pressure is taken to make sure she is not hypertensive. If she is found to be hypertensive, her urine is checked for proteinuria. Her investigations would be to repeat her full blood count to confirm if its thrombocytopenia. Once confirmed to send for full blood picture, coagulation profile, liver function test, urate, lupus anticoagulant, anticardiolipin antibody, anti nuclear antibody, viral serology which includes TORCH, EBV, HIV and malaria. If all results come back normal including the full blood picture a bone marrow aspiration should be the next step of investigation, however this is not indicated in pregnancy unless there is suspicion of lymphoma. If she remains asymptomatic with her platelet levels remaining more than 50x 109/l then no treatment is necessary. She should be followed up by consultant obstetrician for the rest of the antenatal care with regular 2 weekly follow up. Liason with the consultant hematologist is important in considering further management till delivery especially when counts are less than 50x109/l or there is clinical bleeding. Treatment in symptomatic situation is usually with oral corticosteroids which will show response by 3 weeks. If there is no respond intravenous immune globulin is needed. Antenatal referral to the anaesthetist for assessment is carried out. Fetal wellbeing is checked on every visit with ultrasound for growth done. (b) She presents in labour at 38 weeks gestation. Discuss your intra-partum care [7 marks]. Her case notes should be reviewed to see if she has needed any treatment for her low platelets. Her last platelet level should be noted and bloods taken for her current platelet level together with her clotting levels with group and save. Her mode of delivery is based on obstetric indications as there is no benefit in doing a caesarian section for thrombocytopaenia. Liason with the hematologist is important here as she might need platelet transfusion to cover her labour and delivery as well to deal with her hemorrhage. Her fetus might have a small risk of thrombocytopenia at birth and first week of life. Therefore fetal scalp electrode and fetal blood sampling and difficult instrumental delivery should be avoided. If unavoidable an experienced obstetrician should use forceps. The paediatric team should be informed and cord bloods taken at delivery.
		Posted by sonu P. Fri Jul 9, 2010 08:28 am
She will be booked for consultant led care ideally in a joint obstetric-hematology clinic. Early dating scan will be arranged. I will repeat the FBC with all the other booking bloods to confirm the thrombocytopenia. It might be a transient low platelet count due to viral illness or artefact due to clotted blood. A history of easy bruisability or delayed clotting in minor cuts may suggest a pre-existing condition. The commonest reasons of thrombocytopenia in third trimester of pregnancy is gestational thrombocytopenia or immune thrombocytopenia. Although it might be very difficult to distinguish when first detected in pregnancy. Other causes of low platelets like PET and HELLP syndrome would need to be ruled out. I will do repeat FBC in a week and if counts are fairly stable , will be followed up by monthly tests. Both types of thrombocytopenia do not significantly deteriorate in pregnancy. The patient should be managed in close collaboration with hematologists. Usually no treatment is required. In cases of decreasing platelet counts which is uncommon, steroids may be indicated. In immune thrombocytopenia, measures like plasmapheresis and splenectomy are sometimes used as the last resort. Patient would need to be on long term antibiotic prophylaxis post splenectomy. The course of gestational thrombocytopenia is usually benign with good prognosis. Patients presenting in labour with thrombocytopenia should have iv access at the earliest opportunity; FBC, clotting profile and group& save sample should be sent. The patient can have epidural analgesia if counts >80,000. If recent count < 50,000, i.m. injections shoud be avoided.There is a risk of transplacental transmission of IgG anti-platelet antibodies and fetal thrombocytopenia. Therefore, invasive procedures like fetal scalp electrode, fetal blood sampling and difficult instrumental deliveries should be avoided. There is rarely ever the need for platelet transfusion; indication being platelet count < 20,000 in presence of bleeding. There is no convincing evidence about the most appropriate route of delivery as elective caesarean section offers no benefit. The cord blood should be sent for neonatal FBC and the baby should be monitored by the neonatal team with regular platelet counts. Intramuscular vit K should be withheld till the results of cord blood are available. Alternatively, oral vit. K drops can be offered. Complete resolution of maternal platelet counts after delivery confirms the diagnosis for getational thrombocytopenia.
		Posted by S V. Fri Jul 9, 2010 08:30 am
SV A healthy 23 year old woman has been referred to the antenatal clinic at 29 weeks gestation. FBC performed at 28 weeks showed Hb = 11.5g/dl, white cell count = 8.5 x 109/L and a platelet count of 65 x 109/L. (a) Discuss your antenatal management [13 marks]. Antenatal management should take place in a joint obstetric and haematology clinic including obstetrician, haematoloist, haematogy specialist midwife, anaesthetist and paeditarician. A spurious result should be excluded after repeating the sample in a citrated bottle. The most common cause for thrombocytopaenia in pregnancy would be gestational thrombocytopaenia( 70%). It occurs in the 2nd or 3rd trimester and can recur in pregnancies. It is usually mild and platelet counts are usually>70 X109. Preeclampsia( raised Bp with > 300mg/day proteinuria) and HELLP syndrome need to be ruled out as they occur in the third trimester .HELLP can manifest with normal BP and no proteinuria with thrombocytopaenia , elevated transaminases and haemolysis. Isoimmune thrombocytopaenia forms maternal antobodies against fetal HPA1 antigens causing platelet destruction with fatal consequences like FNAIt, NAIT(fetal and neonatal alloimmune thrombocytopaenia) intracranial haemmorhage.Avoid fetal cordocentesis as high risk (2%) of haemmorhage and death.Therefore the neonatal team need to be informed of baby to be checked at delivery. Other rarer causes to be excluded would be immune conditions like TTP ( previous thrombocytopaenia),SLE( joint pains, rashes) and infections like HIV and CMV( fllu like illness).Fever with neurological symptomas or renal dysfunctions would indicateTTP or haemolytic uraemic syndrome . Drugs like heparin cause drug-associated thrombocytopaenia more with unfractionated heparin and rare with low molecular weight heparin. Symptoms of thrombocytopaenia include bruising, petechiae and bleeding gums.severe bleeding rarely occurs with counts > 20X109.A platelets count of 50X109/l is required for vaginal delivery and operative delivery and above 80 for regional analgesia.An antenatal assessment by the anaesthetist would help assess for regional anaesthesia and for other forms of analgesia if severe thromboctopaenia. If platelets count is low and need to be optimised prior to labour, prednisolone 20mg upto 60mg can be commenced which usually improves platelet count within 4 weeks. Steroid rsistant cases or if counts need to be increased rapidly iv Immunoglobulin sould be used.other treatments are anti D immunoglobulin,azathiprine,platelet transfusion and splenectomy (b) She presents in labour at 38 weeks gestation. Discuss your intra-partum care [7 marks]. The main aim is to have optimal platelet counts( > 80X 109) to prevent severe bleeding. An iv access should be obtained and bloods for FBC and G&S should be sent. If platelet counts are very low or severe bleeding, platelet transfusion should be considered. Her last platelet count should be checked .If the platelet count is less than 80X10*9/l, the patient should be managed with the haematologist and anaesthetist. Fetal scalp electrodes , fetal blood sampling, high and mid cavity instrumental delivery should be avoided in labour as the fetus could have severe thrombocytopaenia.Caesarean section only for obstetric indications. Cord bloods should be taken at delivery to check platelet count. the neonate should be monitored and bloods repeated in on the neonate immediately and in 3-4 days .iv immunoglobulin or platelet transfusion should be considered if neonate is severly thrombocytopaenic.Im vitamin K should be avoided. The mother should be counselled regarding risk of recurrance .
		Posted by zara A. Fri Jul 9, 2010 10:12 am
a]The antenatal management of this lady with thrombocytopenia depend on cause of thrombocytopenia .The cause could be supurious.immune thrombocytopenia.gestationalthrombocytopenia,preeclampsia.hellp syndrome,viral.To establish the cause history should be taken of parity,previous pregnancies ,iugr in previous pregnancies,[indicate antiphospholipid syndrome ]any thrombocytopenia in previous pregnancies and improving after delivery indicates gestational thrombocytopenia in current pregnancy.hellp syndrome ,may recur .family histoy of thrombocytopenia taken.Antenatal record reviewed to look for her bp record,she should be asked about epigastric pain,headache ,blurring of vision as it indicate hellp syndrome.She shoud be asked about flu like illness recently [viral infection]She should inquired about any bleeding from gums,epistaxis ,any bruising.Any recent . Examination should be done to look for petechiea. bruises,.Her blood pressure recorded , check for oedema and clonus,to exclude hellp syndrome.Abdominal examination done for splenomegaly[enlarged in immune thrombocytopenia]and fundal height should be recordedto detect IUGR[PRESENT IN HELLP AND ANTIPHOPHOLIPID SYNDROME].Investigations should be undertaken to establish cause.FBC should repeated with citrate to exclude supurious thrombocytopenia.antiplatelet antibodies should done ,if positive indicate immune thrombocytopenia but may be positive in gestational thrombocytopenia.ANTI nuclear antibodies.lupus anticoagulant ,anti cardiolipin antibodies to exclude antiphospholipidsyndrome and SLE.LFTs,renal function tests,serum urate ,LDH levels ,urine for poteinuria, to look for hellp syndrome .Management of this lady shouldbe consultantled in liasian with haematologist in joint obstetric and haematology clinic,anaesthetic review should be arranged ,involve neonatologist.If immune thrombocytopenia ,explain woman risk of maternal bleeding ,and risk to foetus small risk of intracranial haemorrhage.Serial monitering of platelet required 2 weekly.Aim of management is to keep platelet adequate level,count should not fall below 50 x109 in antenatal,intrapartum,postpartum to prevent maternal haemorrhage.plan should be documented in notes.if count fall below 50x109,steroids should be given 20 to 60mg for 2 to3 weeks ,when count improvestaper gradually.During therapy moniter for side effects of therapylike diabetes and psychosis and moniter for these complications. IF no response to steriods,iv immmunoglobulins should be given,expensive ,allergic reaction can occur.Immunoglobulins prolongs clearence of immune complexes.AntiD can be given in RHpositive patients.PLatelet transfusion may be required if acute haemorrhage occurs .Splenectomy should be considered as last resort in resistent cases .Regarding fetal monitering no role of fetal blood sampling.If GESTATIONALthrombocytopenia serial pletelet count should done 2weekly .Rarely count fall below 80x109,but if fall consider alternative diagnosis and manage as immune thrombocytopenia.IfHELLP syndrome then main stay of treatment is delivery,after maternal stabilisation with antihypertensive ,and correction of coagulation and platelets abnormalities and steroid cover.IF viral infection then supportive care.IF antiphospholipid syndrome aspirin and heparin given .[b]PATIENT should be delivered in consultant led unit with back up fascilities of blood bank.Woman should be managed in liasain with haemotologist and anaesthetist.Neonatologist should be informed.REview her antenatal record for plan of management and look for recent platelet count.IV line should be established.BLOOD should be sent for cross match,platelet count and coagulation screen .For vaginal and instrumental delivery count should be above 50x109.The epidural canbe given if count above80x109.Aim is to deliver vaginally ,csection reserved for obstetric indications.To prevent fetal cephalhaemaotoma fetal scalp sampling,instrumental delivery ,scalp electrode avoided.cord blood of baby taken .Prompt perineal repair should be done.Be vigilant to detect pph.Baby handed to neonatologist .MATERNAL platelet count repeated after delivery .
		Posted by Mohamed D. Fri Jul 9, 2010 12:18 pm
Mohamed A) Platelet count of less than 100x109/L is considered thrombocytopenia and referral to consultant led care is advised, with multidisciplinary care with haematologist and anaesthetist. Repeat FBC in 1-2 weeks with blood film to role out platelet clumping or artefact and if still low continue with consultant led care. Check if she is having a preeclampsia; with checking her BP, urine protein and symptoms of headache, and epigastric pain should be investigated. Check her liver and kidney functions to role out preeclampsia or HELLP syndrome. Ask about any history of bleeding or bruises before to role out undiagnosed ITP and if any previous platelet cout especially before pregnancy. Bloods should be checked for autoimmune profile. Anticardiolipin antibodies and lupus anticoagulant to role out immune thrombocytopenia. Examination for any bruises or petichae to check for undiagnosed ITP. Platelet count should be checked monthly till the third trimester and then twice weekly till delivery. Steroid treatment can be tried with lower platelet count < 50, with counselling. Refer to haematologist if underlying cause is suspected for follow up. Induction of labour for obstetric indication only and no extra scans needed during antenatal period. B) Inform medical staff, IV access and blood for FBC and group and save serum for risk of bleeding. Epidural in not contraindicated if a recent platelet count of 80 or more. It can be given in lower platelet count after proper risk benefit assessment with no risk of bleeding and counselling for risk of spinal haematoma. Caesarean section is for obstetric indication only. The risk of bleeding is small with platelet count more than 50 and platelet transfusion only if platelet count is less than 10-20 with bleeding. FSE, FBS, and operative vaginal delivery is not contraindicated as there is a small risk of neonatal thrombocytopenia. Cord blood should be taken for neonatal platelet count to role out neonatal thrombocytopenia. Avoid NSAIDs as it exacerbate the condition and codeine analegisia should be used instead. Breast feeding is not contraindicated. A 6 weeks postnatal review should be arranged with FBC and haematology review.
		Posted by Chitra.s M. Fri Jul 9, 2010 06:13 pm
A. The woman\'s antenatal records are reviewed for platelet counts at booking.She is enqiured about any recent viral/flu-like illness which may be the cause for thrombocytopenia.History of easy bruisability or bleeding from gums is noted.Any history of drug intake like heparin is asked about.Past obstetric history is enqiured for low platelet count in previous pregnancies and neonatal outcomes.Family and past history of thrombocytopenia is asked about.She is examined for anaemia and jaundice.The woman is examined to note her pulse, bloodpressure and temperature.Abdominal examination is done for uterine size and FHS.Skin examination is done for presence of bruises. Full blood count is repeated for platelet counts and peripheral smear for platelet distribution,any clumping and evidence of hemolysis.Liver function tests are offered to rule out HELLP syndrome as a cause for thrombocytopenia.Clotting studies are indicated if repeat platelet count is low.Screening for viral infections like HIV is offered if she is from high risk population.RFT is done to exclude cause like preeclampsia and TTP/HUS.Urine dipstix examination is done for proteinuria, Management depends on the cause for thrombocytopenia.She is managed by a multidisciplinary team of obstetrician,haematologist,anesthetist & paediatrician.The woman is counselled that severity of maternal thrombocytopenia does not correlate with fetal count.Platelet counts are serially monitored every2-4 weeks.Platelet counts <5010 9/l indicate need for treatment.Oral prednisolone is started & response monitored.She is monitored for complications of steroid treatment like diabetes.Intravenous methyl predisolone is considered if oral steroids are not tolerated.Intravenous immunoglobulin is considered when there is inadequate/no response to steroids and platelet counts are low.Anti D immunoglobulins can be considered if she is Rh positive.Platelet transfusions may be required if platelet counts are very low and/or if she is bleeding. She is referred to anaesthetist consultation for planning labour analgesia/anaesthesia.Plan for delivery is discussed and documented.There is no role for routine labour induction. B.The woman is managed in liaison with hematologist, anaesthetist & paediatrician.Early venous access is established and blood sent for platelet counts, group & save.Platelet transfusion is indicated for very low counts.(<50)One to one care is provided.Regional anaesthesia are not contraindicated if counts>8010 9/l.Continuous electronic fetal monitoring is done.Invasive fetal monitoring with scalp electrodes& fetal blood sampling are best avoided.Caesarean section is done for obstetric indications.Midcavity /rotational forceps and ventouse delivery which may potentially cause trauma to fetal head is avoided.Baby has to be evaluated by neonatologist at birth & cord blood sent for platelet counts.Intramuscular vitamin K is not given until counts available.
		Posted by Arun D. Sat Jul 10, 2010 01:24 am
a) I will explain the result to the patient, will tell her that 8-10 % of all pregnancies are affected by the same condition. 75% of them are caused by a condition known as gestational thrombocytopenia, which is a benign and self limiting condition, platelet count usually remains above 75. Other 15% may be due to immune cause. Rest 10% due to other causes. To assess the etiology, any history of viral fever should be asked,any renal problem in the past or present pregnancy,any history of previous blood transfusion should also be asked. I will also ask her about any such type of problem in previous pregnancy and any treatment or blood transfusion she received or not. Any history of PPH is also to be asked. Any history of gum bleeding, petechial rash, hematuria is also to be asked. I need to rule out pre-eclampsia by measuring BP and urine protein. I shall arrange for other blood test like liver function test,urea and electrolytes, blood smear to rule out other causes of thrombocytopenia. Clotting tests should be performed to rule out functional diseases of platelet. Anesthetic alert needs to be sent to give her an oppertunity to discuss the mode of pain relieef during labour if thrombocytopenia persists at that level. Multidisciplinary management should be done. Her next appointment will be in that obstetric unit where the specialists deal with medical diseases complicationg pregnancy ( maternal medicine unit ) Hematologist referral should be made. Her platelet count should be monitored weekly. b) When she presents in labour, repeat FBC and clotting studies should be done to check her coagulation status. Pain relief should be provided after properly liasing with anaesthetist. Fetal blood sampling should be avoided. Fetal scalp electrode should also be avoided. Intr mascular injection should be avoidd as far as possible. Rotational forceps and mid cavity forceps should be avoided. Active management of 3rd stage of labour is to be done to reduce blood loss. Cord blood platelet to be assessed to check babys platelet.. Paediatrician need to be informed. Platelet count to be repeated post partum. Patient should be explained about the chance of recurrence.
		Posted by Dr Dyslexia V. Sat Jul 10, 2010 01:42 am
X a) She is having thrombocytopenia in the third trimester. She should be managed with a multi disciplinary team which include hematologist, obstetrician, anesthetist, pediatrician, and nurses. Her diagnosis for the cause of the thrombocytopenia should be ascertain for specific part of her management. Careful history of previous thrombocytopenia or low levels of platelet in early pregnancy or booking could indicate idiopathic thrombocytopenic purpura(ITP). History of malar rash, joint pain, athralgia, alopecia which could suggest systemic lupus erythomosus(SLE) or symptoms of severe pre eclampsia such as headache, vomittant, nausea, blurring of vision and epigastric pain. Her blood pressure and urine for proteinorea should also be monitored for possibilities of pre eclampsia and liver function test, lactate dehydrogenase for microangopathic hemolysis in hellpsyndrome. Investigation which should include peripheral blood film to a certain pure thrombocytopenia and not due to platelet clamping. Presence of lupus anticoagulant and anticardiolipin antibody could indicate antiphopolipid syndrome. She would be ideally monitored for her platelet levels 2 weekly till delivery and with monitoring of symptoms such as presence of peticle rash, gum bleeding, or any other bleeding tendencies. Other diagnosis such as cytomegalo virus or dengue could easily be excluded by non presence of pyrexia and the necessary serology test for it. There is risk of fetal growth restriction and thus regular growth scan of fetus should be done especially in preeclampsia and antiphopolipid syndrome which prompts for early delivery. A trial of steroids i.e. prednisolone which is administered 1 miligram per kg body weight to await for response for a period of a week could be done in gestational thrombocytopenia or ITP. Other modalities include administration of intravenous immunoglobin which gives more prompt response. Anti D immunoglobin also could be administered for to increase platelet level. Splenotectomy should be avoided in pregnancy but could be considered in extreme cases. The platelet level needs to be maintained above 80x109 per liter for operating vaginal delivery. A clear documentation of her pregnancy plan should be outlined to facilitate the multi disciplinary approach for her condition. a) Her pregnancy plan should be reviewed and a multi disciplinary team including hematologist, obstetrician, anesthetist, pediatrician, and nurses. Her full blood count should be done and the level of platelet ascertained. Blood products and group and crossmatch should be done on admission. Usually a level of 80x109would be required for epidural anesthesia and operative vaginal delivery. If it is less than this level she will require immediate platelet transfusion to facilitate immediate operative delivery. A level of more than 50 x109 is suffice for spontaneous vaginal delivery. The risk of bleeding must be anticipated thus venous access and blood products should be available and the blood bank alerted. Ceasarean section is only done for obstetric indication. No internal CTG or fetal blood sampling done as there could be presence of fetal thrombocytopenia in 4% of the case. Mid cavity operative vaginal delivery must be avoided. Pediatrician should be informed in regards to mother’s thrombocytopenic status and cord blood taken for platelet estimation on delivery and day 4 of life. Intra muscular injections should be avoided in the neonate till platelet levels are known. Active 3rd stage of labor done to minimize blood loss. She should be monitored closely in post natal for secondary post partum hemorrhage. She should be advised to repeat the levels post partum after 6 weeks in which it will resolve to normal levels in gestational thrombocytopenia and persists in ITP. She should be informed of recurrence in future pregnancy especially in event of bleeding episode in neonates in this pregnancy.
		Posted by A A. Sat Jul 10, 2010 07:22 pm
A.A a) Her blood report indicates moderate thrombocytopenia (platelet count between 50-100 x 109/ L) ).In a healthy pregnant woman if asymptomatic, it is most likely due to gestational thrombocytopenia( GT) or idiopathic immune thrombocytopenia (ITP).It is difficult to distinguish between the two as antiplatelet antibodies may be present in GT and the absence of anti platelet antibodies does not exclude ITP. Management is same for both. Other causes like PET , HELLP syndrome ,infections or immune disorders are less likely but need to be excluded. GT is a benign condition mostly without any maternal /fetal bleeding risks, it resolves spontaneously after delivery.Count is typically >70,but less than 70 have been reported .I take history & ask her parity if multiparous there might be a history of GT but no thrombocytopenia outside the pregnancy. ITP usually diagnosis is already established before pregnancy but may occur in pregnancy and is a diagnosis of exclusion. I will review her booking blood , recent drop in third trimester with normal booking platelet count points to GT . Any recent complaint of excessive bruising, gum bleeding or epistaxis. To exclude other causes I will ask for family history of low platelets ( ITP or hereditary) , Any history of headache, epigastric pain, visual symptoms( pre eclampsia). Patient unlikely to be on any drug causing low platelets like heparin or rifampicin if healthy. Recent flu like illness may suggest recent viral infection such as CMV as a cause. Examination is undertaken to detect hypertension, petechiae, bruising, and liver enlargement apart from obstetric assessment. Urine dipstix for protein. Investigations include repeat count and peripheral blood film to exclude platelet clumps there by ruling out pseudo thrombocytopenia, U&E, liver function tests,coagulation screen , to rule out PET and HELLP. Viral screen or autoimmune screen if indicated from history. If perisitant low level & other investigations are normal , patient should be reassured, I will explain the diagnosis & explain the need for regular 2 weekly monitoring , or more often if falling levels. There is risk maternal haemorrhage (unusual if > 50x 109/l) Fetal risks are fetal thrombocytopenia(FT) as maternal platelet IgG antibodies cross placenta and may cause fetal or neonatal intracranial haemorrhage whose incidence is about 1% severity of FT is usually not corelated with maternal levels. She should be managed under experienced obstetrician care, and close liaison with hematologist is required. If count l< 50x 109/L or clinical sign /symptoms of bleeding even at higher level corticosteroids should be given until a response is obtained, usually within 4 wks. This should be tapered gradually. There is risk of gestational diabetes and post partum psychosis. If inadequate response with steroids intravenous immunoglobulin should be considered. The response is rapid within 24 -48hours it is ssociated with risk of transmission of infection and allergic reaction. Anti D is equally effective in Rhesue +ve patient Platelet transfusion rarely needed, use only in acute situation ,after discussion with consultant hematologist. Splenectomy must be avoided during pregnancy but may be required rarely. This is associated with risk of preterm labour. Near term consultation with anaesthetist should be arranged to discuss about regional analgesia ,contraindicated if count < 80x109/L. also to discuss alternative such as patient controlled analgesia. No additional Fetal servillance required, unless indicated for other obstetric reason like growth restriction. Delivery in a consultant led unit. Plan of labour should be combine decision of Consultant obstetrician & Hematologist, along with full patient involvement according to platelet levels & her clinical situation. Vaginal delivery is safe & caesarean section is not indicated for thrombocytopenia alone . b) Intrapartum management should be undertaken by multidisciplinary team (senior Obstetrician, haemotologist, anaesthetist and neonatologist). I will check her recent platelet count , An intravenous cannula must be sited in readiness for possible bleeding. I will take bloods for FBC to check for platelets and Hb level & keep platelets / blood cross match ready . Vaginal delivery is usually safe . I will inform the anaesthetist to assess for appropriate analgesia. Avoid epidural if level< 80. I will commence a continous CTG to pick up any fetal distress as is the case of abruption which may occur. consider platelet transfusion if platelet is less than 50. I will cover labour with intravenous steroids (hydrocortisone 100mg 6 hourly) if patient on steroids for more than 2-3 week before labour . Avoid the use of fetal scalp electrode, fetal blood sampling and operative vaginal delivery as there is risk of fetal intracranial hemorrhage. Caesarean section would be for obstetric reasons. Active management of 3rd stage to reduce risk of PPH.. Cord blood at delivery to check for platelet levels in the neonate followed by capillary blood for confirmation if found to be low. Avoid I/M vit. K to neonate ,oral can be given until platelet count available.
		Posted by NIRMALA M. Sun Jul 11, 2010 01:34 am
Thrombocytopenia complicates about 5-10% of pregnancies at term. Normal platelet count is about 150-400 X 10`9 /l . In antenatal period, the platelet count should be maintained atleast above 50 X 10`9/l. At delivery, the platelet count should be maintained above 80 X 10`9/l. In this patient, who was healthy so far, presenting with a single episode of thrombocytopenia, I would like to repeat her platelet count in a citrate tube as it might be due to spurious thrombocytopenia. I would also check her booking platelet count to compare with the present one. If the repeat platelet count is also low, then she should be referred to a consultant led clinic with special interest in maternal medicine. She has to be managed in liason with Haematologist. She has to be referred to anaesthetic Consultant as well to make a clear plan for her regional anaesthesia for pain relief in labour. Though she is healthy, I will quickly ask about any of the following symptoms occuring lately like headache, flashing of light, abdominal pain if related to pre-eclampsia, any signs and symptoms of infections like fever, recent blood transfusions, arthralgia, recurrent miscarriages if related to APLA/ SLE any CNS symptoms to rule out TTP, which is very unlikely in this case. I will also ask her whether she had thrombocytopenia in previous pregnancies if multi para, or any history of bleeding problems in the past. I would examine her and look for hypertension, splenomegaly, SFH to rule out FGR, epigastric tenderness in cases of HELLP and severe preeclampsia. I would do bloods like urea, creatinine, uric acid, coagulation screen, LFTs to include LDH as increased in HELLP and HUS-TTP. Peripheral blood film to see hemolysis, reticulocytosis which happens in HELLP and HUS-TTP, APLA screen and screen for auto immune disorders. Urine to look for proteins and infection. USS to assess fetal growth, liquor and if suspected FGR, to include dopplers. Treatment should be based on the underlying cause. If no cause has been found then diagnosis is narrowed down to either gestational thrombocytopenia or ITP, both were diagnosis of exclusion. In this patient, gestational thrombocytopenia is very much unlikely as the platelets is usually above 80 X 10`9/l in this condition and it presents late in third trimester. Therefore If all causes have been excluded, it might be due to Idiopathic thrombocytopenic purpura in this patient. Her platelets should be monitored every 2 -4 weeks and if it is dropping further and below 50 X 10`9/l, treatment should be commenced after counselling. The first line treatment is prednisolone 1mg/kg/day till platelets are above 50 X 10`9/l, then can be tapered to maintain at that level. If resistant, then consider IV immunoglobulins. But the response is temporary and need to repeat every 4 weeks. Allergic reactions and infection risks should be bourne in mind with immunoglobulins. In refractory cases, splenectomy should be considered during pregnancy, if possible can be considered along with Caesarean section in II or III trimester. No need of platelet transfusion antenatally for thrombocytopenia as it does not improve the platelet count as it would be destructed immediately by the antibodies. If the diagnosis is HELLP syndrome, she has to be delivered immediately. If the diagnosis is Preeclampsia, then her BP should be well controlled with anti hypertensives and PET bloods monitored and delivery depending on the clinical severity. HUS-TTP is very unlikely in this lady as she did not had any acute symptoms. Intrapartum management: Aim to maintain her platelets well above 80 X 10`9/l at delivery to make her suitable for regional analgesia. If not, aim to maintain platelets above 50 X 10`9/l. Below this level, there is high risk of APH. Treatment should be provided before delivery in liason with Haematologist. Aim for induction during the day in the weekdays if not been into spontaneous labour. Aim for normal vaginal delivery. Continuous CTG monitoring should be done during the active phase. Anaesthetist should be involved in order to decide on the type of anaesthesia based on the platelet count. In cases of emergency Caesarean section, she should have GA, if her platelets are less than 50 X 10`9/l. No place for FBS, fetal scalp electrode, Ventouse, difficult or rotational forceps if Platelets are less than 80 X 10`9/l. Platelets should be ready for transfusion if less than 50 X 10`9/l. But transfused only if any bleeding. Cord blood should be checked for neonatal thrombocytopenia. If present, should be repeated every day till 5 days as nadir is reached only at 2-5 days. Perineal episiotomy or tear repair should be done promptly without delay. Avoid NSAIDs in post partum period. Thromboprophylaxis is safe if platelet count is above 50 X 10`9/l.
		Posted by KWASI RICHARD A. Sun Jul 11, 2010 07:30 am
Review her medical and obstetrics history about the use of medications of like heparin or trimethoprim and alcohol histroy which might predispose to thrombocytopaenia,. Any family history of bleeding tendency should be sought. A recent history of flu-like symptoms, illness or headache would suggest a viral infection. Enquire about other central nervous system symptoms like drowsiness and seizures and also about abdominal symptoms and arthalgia and whether she has noted any epistaxis, bruising and bleeding gums especially after brushing teeth. Examination looking for petechiae, purpura and mucosal bellding. Examine for splenomegaly or hepatomegaly. Check reflexes and presence of clonus. Investigations should include a full blood count. It is important to compare this to the count at booking visit and a peripheral blood film. Reticulocyte count and lactate dehydrogenase. Exclude spurious thrombocytopaenia. Repeat platelet count in citrate to prevent clumping. Check blood pressure and do urinalysis. Assessment of clotting status, renal and liver function test and urate levels. Determination of the presence and absence of lupus anticoagulant and anti-cardiolipin antibodies and antiplatelet antibodies and virology screen. Close liaison between haematologist and obstetricians. Review the woman one week after investigations to review results and repeat blood count to ensure that platelet count is not decreasing rapidly. Bone marrow aspiration may be needed to consider severe thrombocytopaenia or if there is rapid fall in platelet count. Monitor platelet count every two weeks and aim for safe platelet count for delivery (>80). If platelet count falls below 50 corticosteroid therapy should be considered. An anaesthetist review to discuss regional anaesthesia plan and paediatrics to discuss implications to the fetus/baby. Inform anaesthetist and paediatrician of delivery. If platelet count is less than 80 avoid regional anaesthesia. If platelet count is less than 50 platelets should be available and use only if active bleeding. Aim for vaginal birth. Caesarean section is not routinely recommended as there is no evidence that this will reduce the incidence of intracranial haemorrhage. Avoid fetal scalp electrode, fetal blood sampling, ventouse delivery and difficult forceps delivery. A cord sample should be taken to assess neonatal platelet count.
		Posted by Ir A. Sun Jul 11, 2010 12:19 pm
I would like to rule out any underlying cause for her thrombocytopenia. I will enquire about symptoms of easy bruisability, epistaxis, bleeding form gastrointestinal tract or hematuria. I will ask her about any recent fever, viral illness or drug intake. I will ask her about any similar history in previous pregnancies or any family history. I will measure her blood pressure and urine protein to rule out pregnancy induced hypertension or preeclamsia. I will examine her for any petechiae. I will explain to her that idiopathic thrombocytopenia may complicate upto 10% of pregnancies and results from haemodilution in pregnancy. The risks to the mother and fetus are very low. She will receive routine antenatal care with regular monitoring of the platelet count. The treatment options of steroids, IVIG and platelet transfusion should be discussed with her in case her counts fall further. I will explain to her that vaginal delivery can be allowed safely at counts above 40,000 but epidural anaesthesia will be contraindicated. She should deliver in a consultant led unit and managed in conjunction with a hematologist. Bone marrow aspiration is not indicated unless there are unusual features or lack of response to standard treatment. When she presents in labour, i will repeat her full blood count and do group and cross match. I will alert the blood bank and request them to keep platelets on stand by. If her counts are less than 40,000 she will require platelet transfusion. Epidural anesthesia is contraindicated at counts below 80,000 and alternate analgesia should be offered. I will avoid any fetal blood sampling or scalp electrodes. Operative vaginal delivery should not be attempted at counts below 50,000. Cesarean would be reserved for obstetric indications. I will alert the neonatologist as the baby is at risk of thrombocytopenis and intracranial haemorrhage. Cord blood should be taken at the time of delivery to ensure that the baby\'s counts are normal. It should be repeated at day 1 and 4 of life. Maternal therapy with steroids or platelet transfusion does not benefit the baby.
		Posted by Bobey B. Sun Jul 11, 2010 06:50 pm
Antenatal management would initially directed to the establishment of diagnosis. The differential diagnosis to be considered would depend on whether there were other significant features ( petechiae, echymosis ,nose and gum bleeding) or this was an isolated finding. In this case , the platelet count seen to be isolated finding and the woman is healthy, but the underlying pathological cause such as preeclampsia , antiphospholipid syndrome , non-specific bone marrow suppression due to infection or drug induced must still be considered. The two most likely primary conditions in such case are gestational thrombocytopenia ( G T ) and maternal immune thrombocytopenia ( ITP ). Multidisciplinary input from haematologist , pediatrician and anaesthetist is important. The platelet count must be monitored with serial full blood counts at 3-4 weeks interval. G T and ITP can be differentiated by autoantibody screen, however the absence of antiplatelet antibody does not exclude the diagnosis of ITP. The ITP is diagnosis of exclusion and should only be made if other systemic disorders or medications / drugs have been excluded . Antenatally , management would depend on the problem experienced . G T requires neither intervention nor treatment except monitoring of platelet count periodically. Maternal treatment of ITP is recommended in presence of platelet count less than 50.000 /ul or bleeding complication. Corticosteroids e.g. prednisolone are the first line of treatment. Its response time is 3-7 days and maximum effect usually occurs by 2-3 weeks. Its risk includes hyperglycaemia , fluid retention and bone calcium loss. Intravenous immune globulin ( IVIG ) works by binding to platelet , blocking the attachment of antiplatelet antibodies. IVIG is ideal when time is inadequate for steroids to take effect ( prior to surgery or low platelet count with bleeding ) . IVIG is preferable in women require high maintenance dose of prednisolone or who are intolerant for prednisolone. The response time of IVIG is 6-72 hrs and last for 30 days, but it is expensive. Anti-D immunoglobulin can be used in Rh-positive , nonsplenectomized women but risk/benefit ratios need to be considered prior to its useage. Platelets infusion would be considered in the case of spontaneous bruising and bleeding or platelet count less than 50.000 /ul or prior to surgery. Autoimmune ITP may be associated with fetal TTP( thrombocytopenia ) due to the passage of IgG antiplatelet auto-antibodies across the placenta. It may associated with intracranial haemorrhage in approximately 1% of cases. Maternal platelet count is a poor predictor for fetal or neonatal TTP. Steroids or IVIG do not reliably prevent the fetal TTP. Cordocentesis carries a 1-2 % risk of emergency caesarean section due to its morbidity .The transfer of antiplatelet antibodies occurs at the end of pregnancy, so , there is no place for serial fetal blood sampling. Antepartum anaesthesia consultation should be obtained to discuss availability of regional analgesia. b) Vaginal delivery never has been proven to cause intracranial haemorrhage. Caesarean deliveries for GT or ITP should be reserved for obstetrical indications only . Invasive procedures such as ventouse and fetal blood sampling must be avoided . Cross-matched blood and platelets should be available. Epidural analgesia cannot be given when platelet count is below 50.000 / ul ,in view of the risk of haematoma formation. If maternal platelet count is less than 40.000/ul , then platelet transfusion is required if caesarean section is warranted to avoid excessive bleeding. An uncomplicated vaginal delivery is the safest mode of delivery for both mother and baby. Neonate should have platelet count assessed from cord blood . Owing to the increased risk of haemorrhage , soft tissue damage should be avoided , prompt perineal repair effected and the third stage actively managed.
		Posted by Bgk H. Sun Jul 11, 2010 07:01 pm
bgk a. Patient is most probably has Gestational Thrombocytopaenia (GT) although other diagnosis need to be excluded. She need to be manage in multidisciplinary team including haematologist, obstetricians with special interest and neonatologist. I will repeat the test to rule out any labarotory error or platelet clumping that may present as low platelet count. I will review her booking platelet count and compare as gestational thrombocytopaenia will normally onset at third trimester. if it is present at early pregnancy, other diagnosis such as Idiopatic Thrombocytopaenia need to be considered. Sign and symptoms of easy bruising and bleeding tendencies is unlikely to acompany GT. I will ask about history of viral illness as it is one of the causes of thrombocytopaenia. Siign of symptoms of impending eclampsia need to be asked as this may cause low platelet cound and may be associated with HELLP syndrome. I will ask her past obstetrics history, as GT is likely to recur in subsequent pregnancy. If present outcome and managemnt of the pregnancy need to be explored. Past medical history such as Haemolytic Uraemic syndrome and Microangiopathic Haemolitic Anaemia need to be reviewed as it may be one of the causes. Medication that may cause thrombocytopaenia such as heparin need to be asked. On clinical examination signs of bleeding tendencies such as purpura need to be elicited. I will rule any high blood pressure and any fever that may suggest febrile illnessess. After establishing her diagnosis, she is best managed alongside with haematologist in combine clinic together obstetricians with special interest. Mother should be explain regarding the diagnosis and reassured if Gesattional Thrombocytopaenia as there is rarely any intervention during antental period. Repeat and serial platelet count should be done in 2 weekly. Conservative management is justified for platelent count more than 20x109/L. And a persistenly low platet toward term, oral corticosteroids should be given as a joint decision with haematologists. Early referral to anaesthetist is needed to discuss about the pain relief in labour anfd requirement of operative abdominal delivery. Induction of labour at term is recommended as to makesure the delivery at a controll situation with the presence of anaesthetist and neonatologists. Patient information sheet should be given. b. This is a high risk labour. Multidisciplinry aproach needed with one to one nursing care and continous CTG monitoring. She should be manage in tertiary delivery unit. Haematologist should be aware about the patient and platelet need to be in reserved. Early anaesthetic referral needed for the pain relief in labour. Progress of labour charted as perprotocol. Fetal blood sampling and fetal scalp electrode placement should be avoided. If instrumentation needed, vacuum delivery should be avoided and high midcavity forcep is not recomended. after delivery neonatalogist should be presence and assess the baby. Cord blood need to be taken to dtermine the platelet count. Active third stage management needed including IM ergometrine, controll cord traction and oxytocin infusion needed. Breast feeding not containdicated.
		Posted by millionaire2004 A. Sun Jul 11, 2010 10:16 pm
Ag. a) This woman has thrombocytopenia and it is usually benign in nature. However, it need to be investigated as it carries significant maternal and neonatal morbidity such as postpartum hemorrhage and fetal intracranial bleeding.platelet count need to be repeated to exclude laboratory error. Obtain history regarding previously affected pregnancies (if any) and the course of the disease. Rapid improvement in platelet postpartum count could point to a diagnosis of gestational thrombocytopenia or immune thrombocytopenia. Low prepregnancy platelet count could indicate a diagnosis of congenital thrombocytopenia. Measure blood pressure,proteinuria and liver enzymes to exclude syndrome of hemolysis,elevated liver enzymes and low platelet (HELLP). HELLP syndrome could still occur without hypertension and protenuria. Microangiopathies are unlikely in a healthy woman. She should be managed by a multidisciplinary team comprising of a hematologist,obstetrician,anaesthetist,paeditrician and midwife. Arrange regular follow up 2 to 4 weekly in a combine clinic run by obstetrician and hematologist. measure platelet level, blood pressure and protenuria each visit. Inform the woman that risk of bleeding is low but need to consult her obstetrician if she develop abdominal pain with/without per vaginal bleeding, to exclude abruptian. Advice the woman that vaginal delivery is generally safe with platelet count of more than 50000 million/L. Arrange meeting with anaesthetist to discuss regarding intrapartum pain relief as epidural may not be possible. Inform her that platelet transfusion may be needed peripartum,but this is rare. Discuss with her risk and benefit of blood product transfusion. inform her that risk of neonatal bleeding is low, however the risk is increased if she has a previous child with thrombocytopenia. b)Check her platelet count on admission. if count > 50000 milion/L , can allow vaginal delivery if no obstetrics contraindication. Caesarean section is reserved for obstetrics indication. Reserve platelet in delivery suite if platelet count reaching 50000 million /L. May need to transfuse platelet during impending delivery or prior to caesarean section depending on platelet count. Avoid procedures that traumatise fetal head such as fetal blood sampling,fetal scalp electrode placement of midcavity forceps delivery. This can lead to fetal bleeding in fetal thrombocytopenia. Active management of third stage to reduce risk of postpartum hemorrhage. General anaesthesia preferred than regional anaesthesia for caesarean section to reduce risk of cord compression by haematoma. postnatally, check fetal platelet count before administrating intramuscular vitamin K injection. Maternal platelet count repeated in post natal ward.
		Posted by KWASI RICHARD A. Tue Jul 13, 2010 07:21 pm
HI PAUL PLEASE I POSTED MY REPLY TO THE THE QUESTION ON THROMBOCYTOPAENIA ON THE 10/7/10 HOWEVER IT HAS STILL NOT BEEN MARKED COULD YOU PLEASE CHECK IT .THANK YOU RICHARD .I JUST WANT TO KNOW HOW I AM DOING