Gestational Thrombocytopenia – a Diagnosis of Exclusion
Thrombocytopenia is a common finding which occurs in 7-12% of pregnant women. The cause of isolated thrombocytopenia may be differentiated by history, physical examination, laboratory investigation, and medical imaging.
When evaluating a patient for gestational thrombocytopenia (GT), consider the following
≥Use platelet count <150 x 109/L to define thrombocytopenia in pregnancy
Normal platelet range in nonpregnant women is 165-415 x 109/L
Expect lower platelet counts in pregnant women, especially 3rd trimester
Order the following tests to assist with diagnosis/underlying cause
Based on clinical context, may require medical imaging to evaluate splenic size
Diagnose GT in the absence of historical, clinical, hematological and biochemical findings that would suggest another underlying condition
Transfuse platelets to achieve minimum platelet counts if
<10 x 109/L even without surgery and/or procedures
<50 x 109/L if active bleeding present unless undergoing cesarean in which case prophylactic platelet transfusion is recommended (or other major surgery as per AABB guidance)
Epidural and spinal “are considered acceptable” if ≥70 x 109/L prior to epidural and
Platelet level stable | No coagulopathy | Platelet function normal | No antiplatelet or anticoagulant therapy
Limited evidence regarding low-dose aspirin combined with thrombocytopenia and neuraxial blockade
GT is the most common cause of thrombocytopenia in pregnancy and accounts for 80% of such cases. GT may be a result of hemodilution and enhanced platelet clearance. The low platelet counts associated with GT are seen during the second and third trimesters with the nadir rarely lower than 70 x 109/L. The diagnosis of GT is made by the presence of a decreased platelet count during pregnancy and should be considered a diagnosis of exclusion. GT usually resolves within days to two months postpartum.
Primary immune thrombocytopenia (ITP) may be difficult to distinguish from GT
ITP induces development of platelet autoantibodies that may cross the placenta
Features that may help distinguish GT from ITP
GT usually mid-late 2nd & 3rd trimester / ITP all trimesters
GT only in pregnancy / ITP may occur outside pregnancy
GT will resolve postpartum / ITP may not resolve
GT does not affect fetus or neonate / ITP may cause neonatal thrombocytopenia
If the diagnosis thrombocytopenia is unclear at the time of delivery, assume ITP and manage accordingly due to fetal/newborn risk for thrombocytopenia
Mode of delivery in ITP should be based on obstetric indications alone
ITP treatment options comparable to non-pregnant management – corticosteroids and intravenous immune globulin (IVIG)
In pregnancy, may start at lower end of prednisone dose (10-20 mg daily) and titrate up
Both GT and ITP may recur
Other disorders resulting in non-isolated thrombocytopenia that will present with other related findings include
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