ACOG Practice Bulletin No. 207: Thrombocytopenia in Pregnancy

Impact of pre-delivery medication treatment on delivery outcome in patients with primary immune thrombocytopenia: a cohort study

BACKGROUND

Clinical research data showed a series of adverse events in the delivery period of primary immune thrombocytopenia (ITP) patients, including high cesarean section rate. Consensus report proposed that for patients with platelet count below 50 × 109/L, prednisone or intravenous immunoglobulins (IVIg) can be given to raise the platelet count in third trimester in preparation for labor.

OBJECTIVES

To evaluate the effect of low-dose prednisone or IVIg therapy on delivery outcomes in patients with ITP.

STUDY DESIGN

This was a cohort study that included pregnant women with ITP from January 2017 to December 2022. Patients with platelet counts of (20-50) ×109/L at the time of delivery (≥34 weeks) and who had not received any medication before were enrolled in the study. Patients were divided into the pre-delivery medication group (oral prednisone or IVIg) and untreated group according to their preferences. The differences in vaginal delivery rate, postpartum bleeding rate, and platelet transfusion volume between the two groups were compared using t-test, Wilcoxon rank-sum test, and χ2 test. Logistic regression analysis was used to identify the factors affecting vaginal delivery rate and postpartum bleeding rate, and multiple linear regression analysis was used to identify the factors affecting platelet transfusion volume.

RESULTS

During the study period, a total of 96 patients with ITP were enrolled, including 70 in the pre-delivery medication group and 26 in the untreated group. The platelet count of pre-delivery medication group was 54.8 ± 34.5 × 109/L, which was significantly higher than that of untreated group 34.4 ± 9.0 × 109/L (p = .004). The vaginal delivery rate of the medication group was higher than the untreated group [60.0% (42/70) vs. 30.8% (8/26), χ2 = 6.49, p = .013]. After adjusting for the proportion of multiparous women and gestational weeks, the results showed that medication therapy during the peripartum period was associated with vaginal delivery (OR = 4.937, 95% CI: 1.511-16.136, p = .008). The postpartum bleeding rates were 22.9% (16/70) and 26.9% (7/26) in the medication group and untreated group, respectively, with no significant difference between the two groups (χ2 = 0.17, p = .789), while the platelet transfusion volume was lower in the medication group than untreated group [(1.1 ± 1.0) vs. (1.6 ± 0.8) U].

CONCLUSION

Pre-delivery medication therapy can increase vaginal delivery rate, reduce platelet transfusion volume, but does not decrease the incidence of postpartum hemorrhage.

Maternal Sepsis

Sepsis is the second leading cause of pregnancy-related mortality in the United States. Early recognition, treatment, and escalation of care for the obstetric patient affected by sepsis mitigate the risk of mortality and improve patient outcomes. In this article, we provide an overview of maternal sepsis and address topics of maternal pathophysiology, early warning signs, diagnostic criteria, early goal-directed therapy, and contemporary critical care practices. We also present an overview of common etiologies of maternal sepsis and suggested treatment approaches.

The Association Between the Maternal Pre-pregnancy Platelet Count and Fecundability in Mainland China: A Population-based Cohort Study

BACKGROUND

Currently, awareness about platelet count (PC) and its consequences for perinatal outcome have increased, but there is little reliable evidence on fecundability.

METHODS

Based on the National Free Pre-conception Check-up Projects supported by the Chinese government, 5,524,886 couples met the inclusion criteria and were included in this cohort study. Cox regression models were adopted to estimate fecundability ratios (FRs) and their 95% confidence intervals (CIs) for pre-pregnancy PC quintiles. Restricted cubic splines were used to flexibly model and visualize the relationship of PC with FRs. Microsoft SQL server and R software were used for data management and analysis.

RESULTS

The median of pre-pregnancy PC among women was 221.00 × 109/L. The first (<177.00 × 109/L) and second quintile (177.00-207.99 × 109/L) of PC showed slightly increased fecundability (Q1: adjusted FR 1.05; 95% CI, 1.04-1.06; Q2: adjusted FR 1.04; 95% CI, 1.03-1.05), while higher quintals (Q4: 236.00-271.99 × 109/L; Q5: ≥272.00 × 109/L) were related to reduction of fecundability, when compared with the third quintile of PC (208.00-235.99 × 109/L) (Q4: adjusted FR 0.96; 95% CI, 0.95-0.97; Q5: adjusted FR 0.88; 95% CI, 0.87-0.89). In the first quintiles (<177.00 × 109/L), only 20.93% women had PC below 129.94 × 109/L. An inverse-U-shaped association was consistently observed among women such that the lower PC within the normal range (<118.03 × 109/L) and higher PC (>223.06 × 109/L) were associated with the risk of reduced female fecundability (P for non-linearity < 0.01).

CONCLUSION

PC is associated with female fecundability. Further classification of PC levels may deepen our understanding of the early warnings and significance of female fecundability.

Genetic basis of pregnancy-associated decreased platelet counts and gestational thrombocytopenia

ABSTRACT

Platelet count reduction occurs throughout pregnancy, with 5% to 12% of pregnant women being diagnosed with gestational thrombocytopenia (GT), characterized by a more marked decrease in platelet count during pregnancy. However, the underlying biological mechanism behind these phenomena remains unclear. Here, we used sequencing data from noninvasive prenatal testing of 100 186 Chinese pregnant individuals and conducted, to our knowledge, the hitherto largest-scale genome-wide association studies on platelet counts during 5 periods of pregnancy (the first, second, and third trimesters, delivery, and the postpartum period) as well as 2 GT statuses (GT platelet count < 150 × 109/L and severe GT platelet count < 100 × 109/L). Our analysis revealed 138 genome-wide significant loci, explaining 10.4% to 12.1% of the observed variation. Interestingly, we identified previously unknown changes in genetic effects on platelet counts during pregnancy for variants present in PEAR1 and CBL, with PEAR1 variants specifically associated with a faster decline in platelet counts. Furthermore, we found that variants present in PEAR1 and TUBB1 increased susceptibility to GT and severe GT. Our study provides insight into the genetic basis of platelet counts and GT in pregnancy, highlighting the critical role of PEAR1 in decreasing platelet counts during pregnancy and the occurrence of GT. Those with pregnancies carrying specific variants associated with declining platelet counts may experience a more pronounced decrease, thereby elevating the risk of GT. These findings lay the groundwork for further investigation into the biological mechanisms and causal implications of GT.

Recombinant human thrombopoietin therapy for primary immune thrombocytopenia in pregnancy: a retrospective comparative cohort study

BACKGROUND

Treatment options for pregnant women with immune thrombocytopenia (ITP) who do not respond to first-line treatment are limited. Few studies have reported the use of recombinant human thrombopoietin (rhTPO) for this subset of patients.

AIMS

To investigate the efficacy and safety of rhTPO in ITP during pregnancy and determine obstetric outcomes and predictors of treatment response.

METHODS

From July 2013 to October 2022, the data of 81 pregnant women with ITP and a platelet count < 30 × 109/L who did not respond to steroids and/or intravenous immunoglobulin were retrospectively analysed. Of these patients, 33 received rhTPO treatment (rhTPO group) while 48 did not (control group). Baseline characteristics, haematological disease outcomes before delivery, obstetric outcomes, and adverse events were compared between groups. In the rhTPO group, a generalised estimating equation (GEE) was used to investigate the factors influencing the response to rhTPO treatment.

RESULTS

The baseline characteristics were comparable between both groups (P > 0.05, both). Compared with controls, rhTPO patients had higher platelet counts (median [interquartile range]: 42 [21.5-67.5] vs. 25 [19-29] × 109/L, P = 0.002), lower bleeding rate (6.1% vs. 25%, P = 0.027), and lower platelet transfusion rate before delivery (57.6% vs. 97.9%, P < 0.001). Gestational weeks of delivery (37.6 [37-38.4] vs 37.1 [37-37.2] weeks, P = 0.001) were longer in the rhTPO group than in the control group. The rates of caesarean section, postpartum haemorrhage, foetal or neonatal complications, and complication types in both groups were similar (all P > 0.05). No liver or renal function impairment or thrombosis cases were observed in the rhTPO group. GEE analysis revealed that the baseline mean platelet volume (MPV) (odds ratio [OR]: 0.522, P = 0.002) and platelet-to-lymphocyte ratio (PLR) (OR: 1.214, P = 0.025) were predictors of response to rhTPO treatment.

CONCLUSION

rhTPO may be an effective and safe treatment option for pregnancies with ITP that do not respond to first-line treatment; it may have slightly prolonged the gestational age of delivery. Patients with a low baseline MPV and high baseline PLR may be more responsive to rhTPO treatment. The present study serves as a foundation for future research.

Navigating the Storm: Managing Fetal and Neonatal Alloimmune Thrombocytopenia (FNAIT) in a High-Risk Pregnancy

Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a rare, life-threatening condition causing significant thrombocytopenia and bleeding with the risk of developing intracerebral hemorrhage (ICH). It results from maternal immunizations against fetal platelet antigens. Here, we report a case of a pregnant patient at 30 weeks gestation who presented to the hospital with a low platelet count of 90 th/mm3 and was found to have anti-human platelet antigen (HPA) 1a, 2b antibodies. She was treated with a weekly infusion of IV immunoglobulins. However, her condition was complicated by the development of hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome, which was treated promptly with a platelet transfusion and intravenous magnesium. Even though the child had severe thrombocytopenia and its associated complications, there were no signs of post-delivery thrombocytopenia or any other adverse effects. This case report highlights the importance of the antenatal management of the FNAIT to prevent severe fetal complications, such as ICH.

Severe maternal thrombocytopenia and prenatal invasive procedures: still a grey zone

Management of severe thrombocytopenia, particularly of ITP, in pregnancy is mainly based on expert consensus and clinical experience while there are no clear indications about the minimum platelet count requested for prenatal diagnosis invasive procedures. Since the lack of specific recommendations we reported our clinical management of a patient suffering from severe thrombocytopenia, undergoing amniocentesis. Due to the anecdotic possibility of maternal and fetal bleeding in case of severe thrombocytopenia, prophylaxis with IVIG or even corticosteroids could be considered as a safer strategy to prevent post-procedural adverse outcomes.

Primary autoimmune thrombocytopenia in pregnancy: maternal and neonatal outcomes

Aim: To evaluate clinical characteristics, maternal and neonatal outcomes among pregnant women with primary autoimmune thrombocytopenia (ITP). Materials and methods: All pregnant women with ITP who had undergone antenatal follow-up and delivery at the Department of Obstetrics and Gynecology at a referral center, between 2011 and 2021, were retrospectively investigated. Patients were evaluated in three groups according to antenatal treatment modality. Results: 42 pregnant women with ITP were included in the study. A total of 29 (%69) pregnant womenhad been diagnosed with ITP before pregnancy and 13(%31) were diagnosed during pregnancy. 17 (%41) pregnant women did not receive any antenatal treatment, and 25 (%59) pregnant women receieved treatment. Postpartum haemorrhage (%50) was reported more frequently in the steroids+IVIG group. A total of 42 pregnancies, 43 babies (one twin pregnancy, 41 singletons) were liveborn. Three neonates (%7) had thrombocytopenia and one of them had intracranial haemorrhage. Conclusions: In pregnancies complicated with ITP, the platelet count is moderately or severely low, which can have adverse maternal and neonatal outcomes. Postpartum haemorrhage is a significant cause of maternal morbidity in cases with ITP. Therefore, pregnant women with ITP should be delivered in facilities that can adequately manage postpartum haemorrhage.

Nonobstetric Surgical Emergencies in Pregnancy

In this article, we discuss the major nonobstetric surgical complications that may occur in pregnancy. We highlight specific diagnostic challenges particularly with imaging modalities and radiation considerations for the fetus. Topics covered in this article include appendicitis, intestinal obstruction, gallstone disease, hepatic rupture, perforated peptic ulcer, mesenteric venous thrombosis, splenic artery aneurysm rupture, and aortic dissection.

Impact of anemia and thrombocytopenia on postpartum hemorrhage risk among women with term singleton pregnancy

Both thrombocytopenia (platelet count < 150 × 10³/µL) and anemia have been associated with postpartum hemorrhage (PPH). However, the impact of thrombocytopenia on PPH risk among women with mild and severe anemia is unknown. We sought to evaluate the association between thrombocytopenia and anemia in increasing risk of PPH. We performed a secondary analysis of a retrospective cohort of pregnant women from 19 hospitals across the United States from 2016 to 2021. Women who had a term singleton pregnancy and hematocrit (Hct) ≤ 33% at delivery were included in the study. The primary outcome was PPH (defined as blood loss ≥ 1000 mL or blood transfusion). We also analyzed the effect of severe anemia (Hct < 28%) on the association between PPH and thrombocytopenia. Chi-squared tests and Fisher's exact tests were used for categorical variables and an independent t-test was used for continuous variables. There were 20,808 women who met our inclusion criteria, of which 1793 (8.6%) had platelet count < 150 × 10³/µL. The prevalence of PPH was 6.4%. Compared with women with normal platelet count, those with thrombocytopenia had 1.3-fold higher odds of PPH [6.8% vs. 4.5%, adjusted OR 1.3 (1.1-1.7)]. Platelet count ≥ 150 × 10³/µL was associated with decreased odds of PPH among patients with hct between 28 and 33% and hct < 28%. In conclusion, anemic women with term singleton pregnancies who delivered with thrombocytopenia had a higher frequency of PPH. Normal platelet count at delivery was protective against PPH in the setting of anemia regardless of severity.

Platelet function in newborns and the women affected by pregnancy-induced hypertension

BACKGROUND

Platelet dysfunction is one of the serious and common complications associated with pregnancy-induced hypertension (PIH). Nevertheless, the role of platelet dysfunction in the newborns of PIH mothers is unclear. This study aimed to study platelet problems in infants and women affected by PIH.

METHODS

A prospective cohort study was conducted on singleton pregnancies who delivered at a gestation age of 32 weeks or more. The women were divided into the PIH group and the normal control group. The blood tests for maternal and neonatal platelet evaluation such as platelet concentration, mean platelet volume (MPV), and clotting time were performed for comparisons between both groups.

RESULTS

A total of 106 cases were recruited for the study (55 cases in the PIH group and 51 cases in the control group). Hematologic studies showed a significant increase in the incidence of thrombocytopenia and platelet dysfunction (increased MPV) in women affected with PIH when compared with those in the control group (p = .028 and p = .001). However, the platelet study in newborns was not significantly different between both groups (p = .680 and p = .265).

CONCLUSIONS

This study supports the theory that endothelial cell damage and platelet aggregation as indicated by thrombocytopenia together with increased MPV levels in maternal affected with PIH. Importantly, this study provides new insight into that these problems in mothers with PIH do not occur in their neonatal vessels, as indicated by normal platelet counts and MPV levels.

Second-trimester abortion care for those with complex medical conditions

PURPOSE OF THE REVIEW

This review focuses on patients who are most likely to experience morbidity associated with second trimester abortion care and risk mitigation strategies.

RECENT FINDINGS

Prior cesarean birth, particularly multiple prior cesarean births, is the most significant risk factor associated with complications during second trimester abortion because of increased risks of hemorrhage, with or without placenta accreta spectrum (PAS), and distorted anatomy, which increases the risk of uterine perforation. Recent data suggests that first trimester ultrasound findings may be predictive of PAS, including multiple lacunae, abnormal uteroplacental interface, and hypervascularity. Multiple common medications interact with mifepristone and are therefore contraindicated; ulipristal shares mifepristone's selective progesterone receptor modulator activity but does not share the same metabolic pathway. Recent data suggests ulipristal may be an effective adjunct for cervical preparation, avoiding potentially mifepristone's drug-drug interactions. Those ending a pregnancy due to severe early-onset hypertensive disorders have a high rate of clinically significant thrombocytopenia: platelet transfusion is recommended for those with platelets <50 000 per cubic millimeter.

SUMMARY

Pregnant people presenting for care in the second trimester may have conditions that make an abortion more technically or medically complex. Clinicians can mitigate much of this increased risk with preprocedural planning, and appropriate intra-operative preparedness.

Risk factors for severe neonatal thrombocytopenia in cases of maternal immune thrombocytopenia

AIM

Maternal immune thrombocytopenia (ITP) may induce neonatal thrombocytopenia (nTP), which carries a risk of neonatal haemorrhagic complications. Some risk factors for nTP have reached consensus such as maternal splenectomy and previous severe nTP, while others such as maternal platelet count have not.

METHODS

We conducted a retrospective cohort study in a university hospital, including 145 neonates of mothers with ITP. We assessed the risk of severe nTP and bleeding complications.

RESULTS

Severe nTP in the first 24 h after birth was more common in case of maternal splenectomy (OR = 4.4) and a previous severe nTP (OR = 46.9). Severe nTP at nadir (lowest platelet count during the initial postnatal days) was more frequent in cases of a previous neonate with severe nTP (OR = 42), maternal treatment during pregnancy (OR = 2.4) and a low maternal platelet count during pregnancy or at delivery. These risk factors were not significantly associated with an increased risk of neonatal haemorrhagic complications.

CONCLUSION

In our population, we confirm the risk of severe nTP in case of maternal splenectomy or previous nTP. By monitoring the platelet count to its nadir, we identified three additional risk factors: maternal treatment during pregnancy and low maternal platelet count during pregnancy or low maternal platelet count at delivery.

Diagnosis and management of thrombocytopenia in pregnancy

Thrombocytopenia, defined as platelet count <150×10⁹/L, is frequently observed by physicians during pregnancy, with an incidence of approximately 10% of all pregnancies. Most of the cases of thrombocytopenia in pregnancy are due to gestational thrombocytopenia, which does not confer an increased risk of maternal bleeding. However, because other causes can be associated with life-threatening events, such as severe bleeding, that can affect to maternal and fetal outcomes, differentiating other cause of thrombocytopenia, which includes preeclampsia, HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome, acute fatty liver of pregnancy, immune thrombocytopenia, hereditary thrombocytopenia, antiphospholipid syndrome, thrombotic thrombocytopenic purpura, and atypical hemolytic uremic syndrome, is important. Understanding the mechanisms and recognition of symptoms and signs are important to decide an adequate line of investigation. In this review, the approach to diagnosis and the management of the thrombocytopenia commonly observed in pregnancy are presented.

Diagnostic Ideas and Management Strategies for Thrombocytopenia of Unknown Causes in Pregnancy

Objective

To summarize the clinical characteristics and treatment options together with the maternal and neonatal prognoses in women with different degrees of thrombocytopenia of unknown causes during pregnancy.

Materials and Methods

One hundred twenty-nine cases meeting the inclusion and exclusion criteria were retrospectively analyzed. Patients were divided into group A (50*10⁹/L) and group B (50*10⁹/L to 100*10⁹/L) according to the lowest level of platelet count during pregnancy. Patients were divided into those found to have thrombocytopenia in the relatively early, middle, and late stages according to the detection period of maternal thrombocytopenia during pregnancy.

Results

There were 72 cases in group A, and 57 cases in group B. There existed statistically significant differences in terms of the proportion of primipara, the proportion with a history of thrombocytopenia, and the median length of pregnancy between the two groups (p < 0.05). The proportion of patients with severe thrombocytopenia as an indication for cesarean delivery was higher in group A than in group B (p < 0.05). More cases were detected at the relatively early stages of pregnancy in group A than in group B (p < 0.05). There was no difference in neonatal hemorrhage and events of thrombocytopenia between the two groups.

Conclusion

Patients with platelet counts below 50*10⁹/L were mostly primipara with a history of thrombocytopenia, most often detected at a relatively early stage of pregnancy, and continued pregnancy might lead to aggravation of the disease. Combination therapy was required for patients with platelet counts below 30*10⁹/L to maintain the platelet counts within a safe range. Cesarean delivery was selected to terminate the pregnancies, and platelet counts should be raised above 50*10⁹/L before surgery. Close monitoring was required for those with platelet counts above 30*10⁹/L. There was no direct correlation between the maternal and neonatal platelet counts.

Mild thrombocytopenia and the risk for postpartum hemorrhage in twin pregnancies

OBJECTIVE

We aimed to investigate the association of mild thrombocytopenia with postpartum hemorrhage (PPH) and blood transfusion among women with twin gestations.

METHODS

A retrospective cohort study (Jan 2015 to May 2019) was performed. Women with twin pregnancies and pre-delivery mild thrombocytopenia were compared to those with normal platelet count. The primary outcome was the rate of PPH, defined as a composite of one or more of the following: (1) need for packed red blood cell transfusion; (2) postpartum hemoglobin decline of ≥3 g/dL; and (3) the use of postpartum uterotonics agents in addition to oxytocin.

RESULTS

Of 1085 women who were included in final analysis, 315 (30.9%) had mild thrombocytopenia (and 770 (69.1%) served as controls. The rate of PPH was increased in the study group (14% vs. 9.4%, P = 0.03), as was the use of uterotonic agents (3.8% vs. 1.3%, respectively, P = 0.02). The rate of blood product transfusion and hemoglobin decline >3 g/dL was not significantly different between the groups. In multivariate logistic regression analysis, mild thrombocytopenia was associated with a higher risk for PPH (OR 1.55 [95% CI 1.02-2.35], P = 0.02).

CONCLUSION

Mild thrombocytopenia in twin pregnancies is associated with an increased risk of interventions such as the use of uterotonic agents.

Gestational Thrombocytopenia: A Review on Recent Updates

Thrombocytopenia is a condition in which the blood platelet count is low. It is well established that the mild thrombocytopenia frequency is higher in normal pregnancy. This type of thrombocytopenia was named pregnancy-induced thrombocytopenia. However, recently, it has been widely known as gestational thrombocytopenia (GT). The rate is higher in women with a prior GT history and multiple pregnancies. However, it appears that GT is a physiological response to the pregnancy; placenta's peculiar structure and its unique blood flow pattern play major roles in GT development. There are no specific, precise, or known underlying pathophysiological mechanisms of GT, and no new specific management strategies are published yet. Therefore, we decided to do a non-systematic review of any recent updates that had been published in PubMed, EMBASE, and Web of Science about the pathophysiology of GT, its treatment, and other related topics.

Managing hepatic complications of pregnancy: practical strategies for clinicians

Liver disorders specific to pregnancy are rare but can have potentially serious consequences for mother and fetus. Pregnancy-related liver disorders are the most common cause of liver disease in otherwise healthy pregnant women and pose a challenge to physicians because of the need to take into account both maternal and fetal health. A good knowledge of these disorders is necessary as prompt diagnosis and appropriate management results in improved maternal and fetal outcomes. This review will focus on pregnancy-specific disorders and will aim to serve as a guide for physicians in their diagnosis, management and subsequent monitoring.

Improving diagnostic accuracy in pregnancy with individualised, gestational age-specific reference intervals

BACKGROUND AND AIMS

Investigations in pregnancy should be interpreted using pregnancy-specific reference intervals (RIs). However, because of the progressive nature of pregnancy, even pregnancy-specific RIs may not be equally representative at different gestations. We proposed that gestational age-specific RIs may increase diagnostic accuracy over those with fixed limits.

MATERIALS AND METHODS

The trajectory of platelets was mapped in 32,778 pregnant women, using 116,798 results. Then we evaluated the accuracy with which a low measurement in early pregnancy (<3^rd centile) predicted thrombocytopaenia at term, compared to the existing limit (<150 x10⁹/L).

RESULTS

Platelets fell by 14.8% between 8-40 weeks. Platelets below the 3^rd centile before 20 weeks predicted thrombocytopaenia at term (<100 x10⁹/L) with a significantly greater degree of accuracy than a fixed limit (AUC 0.86 vs. 0.76, p=0.004).

CONCLUSION

Pregnancy-specific RIs can be defined using routinely collected hospital data, and the abundance of such freely available data enables a detailed investigation of temporal changes throughout gestation. Individualised RIs offer improved accuracy profiles, over and above those already derived specifically from pregnant populations. Clinicians should consider how this may be used to improve diagnostic accuracy for biomarkers used in current clinical practice, and those yet to be defined.

Neuraxial Techniques for Parturients with Thromboprophylaxis or Thrombocytopenia

Pharmacologic thromboprophylaxis from venous thromboembolism (VTE) and thrombocytopenia in pregnancy results in conditions that may preclude the use of neuraxial anesthesia due to a perceived risk of spinal/epidural hematoma. Spinal epidural hematoma is a recognized complication in patients who are hypocoagulable and may lead patients to undergo general anesthesia for delivery or other procedures, which carries numerous complications in obstetric care. A robust understanding of maternal physiologic changes in coagulation status, review of consensus statements, and safety bundles may help to maximize the use of neuraxial anesthesia in obstetric patients who might otherwise be denied these anesthetic techniques.

Mild gestational thrombocytopenia in primiparous women, does it affect risk of early postpartum hemorrhage? A retrospective cohort study

PURPOSE

To assess whether women with mild gestational thrombocytopenia have a higher risk of postpartum hemorrhage.

METHODS

A retrospective computerized database. Primiparous women that delivered at our center (2005-2019) were included; we excluded women with possible etiologies for thrombocytopenia such as systemic lupus or coagulation disorders, and hypertensive disorder of pregnancy. Demographics, obstetric characteristics, and maternal as well as neonatal data were compared between groups. The exposure measure of the study was mild thrombocytopenia (100,000-150,000) versus normal thrombocyte count (>150,000) at admission for labor. Postpartum hemorrhage (PPH) is defined as a clinical estimated blood loss of > 500 mL and/or a hemoglobin drop of ≥ 3 g/dl.

RESULTS

Overall, 39,886 primiparous met the study's criteria, 5,209 (13.1%) had mild gestational thrombocytopenia (mean platelet count of 132.4 ± 13.2, study group) while 34,677 (86.9%) had normal platelet count at admission (mean of 221.6 ± 50.6, comparison group.) PPH occurred in 17.6% of the study group as opposed to 14% in the comparison group (p < .001). Similarly, all measures of increased bleeding were more common in the study group as compared to the comparison group, including rates of hemoglobin drop greater than 4 and 5 gram/dl, parenteral iron infusion, and blood products transfusion. On multivariable analysis, the aOR for PPH among women in the study group was 1.23 [1.11-1.36].

CONCLUSION

Primiparous women with mild gestational thrombocytopenia are at increased risk of peripartum hemorrhage, this should be considered a risk factor when assessing parturients' risk of PPH.

ANALYSIS OF THE PLATELET HEMOSTASIS AMONG PREGNANT WOMEN WITH IMMUNE THROMBOCYTOPENIA

Relevance: Thrombocytopenia is a common hematological problem that accompanies pregnancy. From 5% to 12% of pregnancies are complicated by thrombocytopenia. Gestational thrombocytopenia is the leading cause of complications (70-85%). Immune thrombocytopenia (ITP) is the most frequent reason among pre-pregnancy causes of thrombocytopenia and is responsible for 1-4% of all thrombocytopenia cases during pregnancy. Investigation of the functional potential of the thrombocyte link of hemostasis in conditions of a reduced number of thrombocytes is relevant. The purpose of the study was to analyze the platelet link of hemostasis in pregnant women with ITP of varying severity by the method of light aggregometry. Materials and Methods: Eighty-eight women with gestational and 28 with immune thrombocytopenia were undergoing treatment and delivery at the Institute of Pediatrics, Obstetrics and Gynecology of NAMS of Ukraine (Kyiv, Ukraine) from September 2018 to February 2021. The platelet link of hemostasis was studied in a group of women with immune thrombocytopenia; six (21.4%) of them had severe thrombocytopenia. Results: In mild and moderate immune thrombocytopenia, we noted a decrease in spontaneous and induced platelet aggregation; in severe immune thrombocytopenia, there was no spontaneous and a decreased induced platelet aggregation. This indicated a reduced potential of platelets to perform their direct function – the formation of a thrombus. Conclusion: Immune thrombocytopenia accounts for most pre-pregnancy conditions causing thrombocytopenia in pregnant women. Light aggregometry is a relevant and indicative way to analyze the aggregative ability of platelets. A multidisciplinary team consisting of an obstetrician-gynecologist, hematologist, anesthesiologist, and neonatologist should be involved in the management of such cases to provide effective obstetric care for this category of pregnant women. Risks for the mother and the fetus/newborn should be assessed throughout the pregnancy, considering clinical and laboratory aspects. Delivery of pregnant women with severe thrombocytopenia should be managed at institutions providing the highest level of obstetric and gynecological care.

The Society for Obstetric Anesthesia and Perinatology Interdisciplinary Consensus Statement on Neuraxial Procedures in Obstetric Patients With Thrombocytopenia

Because up to 12% of obstetric patients meet criteria for the diagnosis of thrombocytopenia in pregnancy, it is not infrequent that the anesthesiologist must decide whether to proceed with a neuraxial procedure in an affected patient. Given the potential morbidity associated with general anesthesia for cesarean delivery, thoughtful consideration of which patients with thrombocytopenia are likely to have an increased risk of spinal epidural hematoma with neuraxial procedures, and when these risks outweigh the relative benefits is important to consider and to inform shared decision making with patients. Because there are substantial risks associated with withholding a neuraxial analgesic/anesthetic procedure in obstetric patients, every effort should be made to perform a bleeding history assessment and determine the thrombocytopenia etiology before admission for delivery. Whereas multiple other professional societies (obstetric, interventional pain, and hematologic) have published guidelines addressing platelet thresholds for safe neuraxial procedures, the US anesthesia professional societies have been silent on this topic. Despite a paucity of high-quality data, there are now meta-analyses that provide better estimations of risks. An interdisciplinary taskforce was convened to unite the relevant professional societies, synthesize the data, and provide a practical decision algorithm to help inform risk-benefit discussions and shared decision making with patients. Through a systematic review and modified Delphi process, the taskforce concluded that the best available evidence indicates the risk of spinal epidural hematoma associated with a platelet count ≥70,000 × 106/L is likely to be very low in obstetric patients with thrombocytopenia secondary to gestational thrombocytopenia, immune thrombocytopenia (ITP), and hypertensive disorders of pregnancy in the absence of other risk factors. Ultimately, the decision of whether to proceed with a neuraxial procedure in an obstetric patient with thrombocytopenia occurs within a clinical context. Potentially relevant factors include, but are not limited to, patient comorbidities, obstetric risk factors, airway examination, available airway equipment, risk of general anesthesia, and patient preference.

Severe thrombocytopenia in pregnancy: a retrospective study

: Thrombocytopenia is defined as a platelet count less than 150 000/μl and it is the most common hematologic disease after anemia in pregnancy. This study aims to investigate pregnant women with severe thrombocytopenia (platelet count <50 000/μl). In the relevant literature, few studies have addressed severe thrombocytopenia in pregnancy. This is a retrospective study based on the data from a reference center in Ankara, Turkey between January 2016 and December 2017. The study group consisted of 51 pregnant women who had two platelet counts lower than 50 000/μl. Descriptive statistical methods were utilized to analyze the results. The study analyzed the causes of severe thrombocytopenia, maternal and fetal-neonatal outcomes, and the management of the patients. The common causes of severe thrombocytopenia were hypertensive disorders (66.7%), immune thrombocytopenia (13.7%), massive obstetric hemorrhage (7.8%), and disseminated intravascular coagulation (5.9%). The preterm delivery occurred in 58.8% of the patients, and 46 live-births (two twins), six stillbirths, and one pregnancy termination emerged. Postpartum hemorrhage occurred in four (0.08%) patients, and blood transfusion was performed in 15 (29.4%) patients. The platelet transfusion was required to increase the platelet count of 30 (58.8%) patients. The study showed that the incidence of causes in severe thrombocytopenia in pregnancy varied considerably from mild and moderate thrombocytopenia. Despite severe thrombocytopenia, maternal and neonatal bleeding complications were infrequent in the study group.

Evaluating hemostatic thresholds for neuraxial anesthesia in adults with hemorrhagic disorders and tendencies: A scoping review

Neuraxial anesthesia can be complicated by spinal or epidural hematoma and may result in permanent neurologic injury. There is a paucity of literature characterizing this serious complication in patients with congenital and acquired hemorrhagic disorders or tendencies. The objective of this scoping review was to describe the hemostatic laboratory parameters where neuraxial anesthesia has been administered with and without spinal and epidural hematoma in patients with preexisting hemorrhagic disorders and tendencies, including immune thrombocytopenia, gestational thrombocytopenia, thrombocytopenia associated with hypertensive disorders of pregnancy, platelet function disorders, von Willebrand disease, coagulation factor deficiencies, and fibrinogen disorders. A systematic search of Ovid MEDLINE, CINAHL, Embase, Scopus, and Web of Science was performed. Two authors independently reviewed all titles, abstracts, and full texts to determine study eligibility and extract data. Qualitative synthesis of 91 studies revealed significant gaps in our understanding of the risk of spinal and epidural hematoma in patients with hemorrhagic disorders and tendencies, including few studies of males and in nonobstetric settings. Most reviewed articles were small, retrospective studies at high risk for potential bias. With such low-quality data, we were unable to provide any true estimates of the risk of spinal or epidural hematoma for these patients, nor could we attribute any specific hemostatic or laboratory values to increased risk of hematoma. There is a need both for larger and more rigorously designed and reported studies on this subject and for structured, comprehensive recommendations for safe administration and removal of neuraxial anesthesia in patients with hemorrhagic disorders and tendencies.

Prediction of postpartum hemorrhage in pregnant women with immune thrombocytopenia: Development and validation of the MONITOR model in a nationwide multicenter study

Globally, postpartum hemorrhage (PPH) is the leading cause of maternal death. Women with immune thrombocytopenia (ITP) are at increased risk of developing PPH. Early identification of PPH helps to prevent adverse outcomes, but is underused because clinicians do not have a tool to predict PPH for women with ITP. We therefore conducted a nationwide multicenter retrospective study to develop and validate a prediction model of PPH in patients with ITP. We included 432 pregnant women (677 pregnancies) with primary ITP from 18 academic tertiary centers in China from January 2008 to August 2018. A total of 157 (23.2%) pregnancies experienced PPH. The derivation cohort included 450 pregnancies. For the validation cohort, we included 117 pregnancies in the temporal validation cohort and 110 pregnancies in the geographical validation cohort. We assessed 25 clinical parameters as candidate predictors and used multivariable logistic regression to develop our prediction model. The final model included seven variables and was named MONITOR (maternal complication, WHO bleeding score, antepartum platelet transfusion, placental abnormalities, platelet count, previous uterine surgery, and primiparity). We established an easy-to-use risk heatmap and risk score of PPH based on the seven risk factors. We externally validated this model using both a temporal validation cohort and a geographical validation cohort. The MONITOR model had an AUC of 0.868 (95% CI 0.828-0.909) in internal validation, 0.869 (95% CI 0.802-0.937) in the temporal validation, and 0.811 (95% CI 0.713-0.908) in the geographical validation. Calibration plots demonstrated good agreement between MONITOR-predicted probability and actual observation in both internal validation and external validation. Therefore, we developed and validated a very accurate prediction model for PPH. We hope that the model will contribute to more precise clinical care, decreased adverse outcomes, and better health care resource allocation.

Society of Family Planning clinical recommendations: Management of individuals with bleeding or thrombotic disorders undergoing abortion

Individuals who have bleeding disorders, thrombophilias, a history of venous thromboembolism (VTE), or who are taking anticoagulation medication for other reasons may present for abortion. Clinicians should be aware of risk factors and histories concerning for excessive bleeding and thrombotic disorders around the time of abortion. This document will focus on how to approach abortion planning in these individuals. For first-trimester abortion, procedural abortion (sometimes called surgical abortion) is generally preferred over medical management for individuals with bleeding disorders or who are on anticoagulation. First-trimester procedural abortion in an individual on anticoagulation can generally be done without interruption of anticoagulation. The decision to interrupt anticoagulation for a second-trimester procedure should be individualized. Individuals at high risk for VTE can be offered anticoagulation post-procedure. Individuals with bleeding disorders or who are anticoagulated can safely be offered progestin intrauterine devices. Future research is needed to better assess quantitative blood loss and complications rates with abortion in these populations.

Platelet counts during normal pregnancies and pregnancies complicated with hypertensive disorders

OBJECTIVES

To determine the trajectories of platelet counts and the prevalence of gestational thrombocytopenia (<150 × 10⁹/L) during normal pregnancies and pregnancies with complications, such as hypertensive disorders of pregnancy (HDP), preeclampsia, and fetal growth restriction (FGR).

STUDY DESIGN

A multicenter retrospective study was conducted using laboratory data on women who delivered term singletons at 11 primary maternity care units between 2011 and 2018 (n = 35,045), and non-pregnant women who underwent a medical check-up between 2016 and 2019 (n = 61,189). After 1:1 matching, 28,073 pregnant women and 28,073 non-pregnant women were selected for analysis.

MAIN OUTCOMES MEASURES

The trajectories of platelet counts and prevalence of gestational thrombocytopenia were evaluated in normal pregnant women, pregnant women with complications, and non-pregnant women.

RESULTS

The platelet counts declined throughout pregnancy, with the nadir occurring on postpartum day 1. The platelet counts recovered to the level of the non-pregnant state at postpartum 2-7 days. The mean platelet counts at postpartum day 1 decreased by an estimated 19.8% and 9.7% compared to those in the non-pregnant state and first trimester, respectively. The prevalence of gestational thrombocytopenia in normal pregnant women at 37-41 gestational weeks and in pregnant women with complications of HDP, preeclampsia, and FGR were 6.1%, 7.3%, 17.5%, and 7.7%, respectively.

CONCLUSION

Platelet counts declined throughout pregnancy and recovered to the level of the non-pregnant state in the early postpartum period. Gestational thrombocytopenia is common during normal pregnancy, and its prevalence is significantly higher in women with preeclampsia.

Type 2B von Willebrand Disease in Pregnancy: A Systematic Literature Review

Our objective was to review the maternal characteristics and obstetric complications in women with type 2B von Willebrand disease (VWD). A systematic literature search was conducted using PubMed, Scopus, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. We included all publications that addressed type 2B VWD in pregnancy. Our primary and secondary outcomes were incidence of postpartum hemorrhage (PPH) and incidence of thrombocytopenia in pregnancy. Two reviewers independently identified eligible studies and abstracted data including maternal characteristics, hematologic characteristics, treatment, and delivery outcomes. Twenty studies met inclusion criteria. There were 27 women (32 pregnancies) with type 2B VWD. Primary PPH was reported in 9/20 women (45%) and secondary PPH was reported in 6/13 women (46%). Thrombocytopenia in pregnancy was present in 27/28 women (96%); 23/27 women (85%) had platelet count <100 × 10⁹/L, mean 33.7 ± 22.7 × 10⁹/L. Factor concentrate treatment was administered before delivery (n = 16) and postpartum (n = 18), some women received both. Seventeen deliveries required blood products postpartum with 13/17 (76%) platelet transfusions and 6/17 (35%) red blood cell transfusions. No maternal mortality was reported. Women with type 2B VWD have significant morbidity in pregnancy related to high incidence of severe thrombocytopenia and primary and secondary PPH.

Mild thrombocytopenia prior to elective cesarean section is an independent risk factor for blood transfusion

PURPOSE

Thrombocytopenia is the second most common hematological disorder in pregnancy and complicates approximately 10% of all pregnancies. The data regarding the association of mild thrombocytopenia in women undergoing cesarean section and risk of bleeding or bleeding-related complications are scarce. Thus, the aim of the current study was to assess the association of mild thrombocytopenia with hemorrhage-related morbidities, among patients undergoing elective cesarean section.

METHODS

We performed a retrospective cohort study, in a single tertiary university-affiliated medical center, between 1 January 2012 and 31 May 2019. Medical charts of women who underwent elective cesarean section at term (37^+0/7-41 + ^6/7 weeks of gestations) were retrieved and analyzed. We compared women with mild thrombocytopenia (platelet count of 100-149 × 10³/μL) to women with normal platelet count (150-450 × 10³/μL). The primary outcome was the need for red blood cell transfusion during the index admission. A secondary outcome was severe bleeding not requiring blood transfusion defined as postpartum hemoglobin decline of  ≥ 3 g/dL as compared to the prepartum levels.

RESULTS

During the study period, 1577 women were included in the final analysis, of them 396 (25.11%) had mild thrombocytopenia prior to delivery. As compared to the control group, women with mild thrombocytopenia had higher rates of blood transfusion (3.79 vs. 1.52%, p = 0.01), and had a significant decline in hemoglobin levels. In a multivariable logistic regression model, mild thrombocytopenia was independently associated with blood transfusion with adjusted OR of 2.34 (95% CI 1.10-4.96, p = 0.03).

CONCLUSION

Preoperative mild thrombocytopenia is associated with an increased risk of blood loss and blood transfusion in women undergoing elective CS. More studies are required to assess those observations in context of urgent cesarean sections and whether any preventive measures can reduce the risk for bleeding.

HOW Collaborative position paper on the management of thrombocytopenia in pregnancy

Thrombocytopenia in pregnancy is a common occurrence, affecting up to 10% of women by the time of birth. These recommendations aim to provide pragmatic guidance on the investigation, diagnosis and management of thrombocytopenia in pregnancy; including safety of neuraxial anaesthesia and precautions required for birth. Management of neonatal thrombocytopenia is also addressed. The authors are clinicians representing haematology, obstetric medicine, maternal-fetal medicine, and anaesthesia. Each author conducted a detailed literature review then worked collaboratively to produce a series of unanimous recommendations. The recommendation strength is limited by the lack of high-quality clinical trial data, and represents level C evidence.

Update on the Use of Intravenous Immunoglobulin in Pregnancy

Intravenous immunoglobulin (IVIG) was first administered to humans in the 1980s. The mechanism of action of IVIG is still a subject of debate but the pharmacokinetics have been well characterized, albeit outside of pregnancy. IVIG has been used in pregnancy to treat several nonobstetrical and obstetrical-related conditions. However, current evidence suggests that IVIG use during pregnancy can be recommended for 1) in utero diagnosis of neonatal alloimmune thrombocytopenia; 2) gestational alloimmune liver disease; 3) hemolytic disease of the fetus and newborn for early-onset severe intrauterine disease; 4) antiphospholipid syndrome (APS) when refractory to or contraindicated to standard treatment, or in catastrophic antiphospholipid syndrome; and 5) immune thrombocytopenia when standard treatment is ineffective or rapid increase of platelet counts is needed. All recommendations are based on case series and cohort studies without randomized trials usually because of the rare prevalence of the conditions, the high incidence of adverse outcomes if left untreated, and ethical concerns. In contrast, IVIG therapy cannot be recommended for recurrent pregnancy loss, and the use of IVIG in subgroups of those with recurrent pregnancy loss requires further investigations. For non-obstetrical-related conditions, we recommend using IVIG as indicated for nonpregnant patients. In conclusion, the use of IVIG during pregnancy is an effective treatment in some obstetrical-related conditions with rare serious maternal side effects. However, the precise mechanisms of action and the long-term immunologic effects on the fetus and neonate are poorly understood and merit further investigations.

Update on Thrombocytopenia in Pregnancy

Thrombocytopenia, defined as platelet count < 150,000 mm³, is frequently diagnosed by obstetricians since this parameter is included in routine surveillance during pregnancy, with an incidence of between 7 and 12%. Therefore, decisions regarding subsequent examination and management are primordial. While most of the cases are due to physiological changes, as gestational thrombocytopenia, other causes can be related to severe conditions that can lead to fetal or maternal death. Differentiating these conditions might be challenging: they can be pregnancy-specific (pre-eclampsia/HELLP syndrome [hemolysis, elevated liver enzymes, low platelets]), or not (immune thrombocytopenia purpura, thrombotic thrombocytopenic purpura or hemolytic uremic syndrome). Understanding the mechanisms and recognition of symptoms and signs is essential to decide an adequate line of investigation. The severity of thrombocytopenia, its etiology and gestational age dictates different treatment regimens.

Case Series of Dengue Fever in Peripartum Period: Maternal and Foetal Outcome

Introduction: Dengue fever is a major public health problem in tropical and subtropical areas. There are not many studies concerning the complications of dengue fever in pregnancy. We present four serial cases of dengue fever in pregnancy. Case illustration: Three of four cases were delivered by caesarean section; two of them died during post-caesarean care. All cases had the lowest platelet level below 50,000/µL and were given platelet transfusion during and after delivery; they also showed abnormal liver function tests. For foetal outcome, none tested positive for dengue. Discussion: Complication of dengue infection depends on a combination of host and viral virulence. Regardless of prophylactic platelet transfusion, some studies revealed clinical bleeding in patients with dengue infection due to an intricate effect on the haemostatic system. The adverse foetal outcome may contribute because of placental circulation caused by endothelial damage with increased vascular permeability leading to plasma leakage. There is no national guideline for dengue fever in pregnancy. Conclusions: The management of dengue fever in pregnancy at the tertiary hospital is still suboptimal. Dengue fever around peripartum presents a higher risk of morbidity and mortality for the mother and therefore needs a multidiscipline team approach.

COVID-19 coagulopathy in pregnancy: Critical review, preliminary recommendations, and ISTH registry-Communication from the ISTH SSC for Women's Health

BACKGROUND

Novel coronavirus (SARS-CoV-2), which causes COVID-19, has thus far affected more than 15 million individuals, resulting in more than 600 000 deaths worldwide, and the number continues to rise. In a large systematic review and meta-analysis of the literature including 2567 pregnant women, 7% required intensive care admission, with a maternal mortality ~1% and perinatal mortality below 1%. There has been a rapid increase in publications on COVID-19-associated coagulopathy, including disseminated intravascular coagulopathy and venous thromboembolism, in the non-pregnant population, but very few reports of COVID-19 coagulopathy during pregnancy; leaving us with no guidance for care of this specific population.

METHODS

This is a collaborative effort conducted by a group of experts that was reviewed, critiqued, and approved by the International Society on Thrombosis and Haemostasis Subcommittee for Women's Health Issues in Thrombosis and Hemostasis. A structured literature search was conducted, and the quality of current and emerging evidence was evaluated. Based on the published studies in the non-pregnant and pregnant population with a moderate to high risk of bias as assessed by Newcastle-Ottawa scale and acknowledging the absence of data from randomized clinical trials for management of pregnant women infected with SARS-CoV-2, a consensus in support of a guidance document for COVID-19 coagulopathy in pregnancy was identified.

RESULTS AND CONCLUSIONS

Specific hemostatic issues during pregnancy were highlighted, and preliminary recommendations to assist in the care of COVID-19-affected pregnant women with coagulopathy or thrombotic complications were developed. An international registry to gather data to support the management of COVID-19 and associated coagulopathy in pregnancy was established.

Clinical features of new-onset systemic lupus erythematosus during pregnancy in Central China: a retrospective study of 68 pregnancies

The aim of this study is to explore the clinical features and pregnancy outcomes of Chinese patients with new-onset systemic lupus erythematosus (SLE) during pregnancy or puerperium. We retrospectively evaluated the data of all pregnant women with SLE managed at the First Affiliated Hospital of Zhengzhou University between April 2013 and March 2017. Clinical characteristics, laboratory features, medication use, and pregnancy outcomes were compared between pregnant women with new-onset SLE and pregnant women with pre-existing SLE. Risk factors for adverse pregnancy outcomes were determined using binary regression analyses. Overall, 223 pregnancies in 216 patients were included; 148 (69.6%) patients had a history of SLE, and 68 (30.4%) were diagnosed with SLE during pregnancy or puerperium. Most cases of new-onset SLE (72.1%) occurred during the first and second trimesters. Thrombocytopaenia (especially severe thrombocytopaenia) (76.5% vs 54.2%, P = 0.008; 39.7% vs 15.5%, P = 0.001) and anaemia (especially moderate anaemia) (73.5% vs 56.9%, P = 0.007; 52.9% vs 35.2%, P = 0.035) were more common in women with new-onset SLE than in women with pre-existing SLE and active disease during pregnancy. Additionally, patients with new-onset SLE experienced higher rates of moderate-to-severe disease activity than patients with pre-existing SLE (P < 0.01); disease activity occurred mostly during the first and second trimesters (75.4%). Compared with pre-existing SLE patients, disease activity in new-onset SLE patients occurred mostly in the first trimester (33.3% vs 15.3%, P = 0.043) and less in the third trimester (21.1% vs 47.2%, P < 0.001). Pregnancy loss was significantly higher in patients with new-onset SLE than in patients with pre-existing SLE (62.4% vs 27.1%, P < 0.001), with most cases occurring during the first and second trimesters (95.3%). However, there were no significant differences in neonatal outcomes between new-onset and pre-existing SLE patients with active disease. Within the new-onset SLE group, active disease was an independent risk factor for pregnancy loss (odds ratio [OR] = 16.185, confidence interval [CI] = 1.895-138.232, P = 0.011), whereas disease onset at late gestation was a protective factor against pregnancy loss (OR = 0.589, CI = 0.435-0.796, P = 0.013). Patients with new-onset SLE suffered greater haematological involvement (mainly thrombocytopaenia and anaemia) and higher rates of moderate-to-severe disease activity and pregnancy loss than patients with pre-existing SLE. Controlling disease activity and extending gestational age may improve pregnancy outcomes in women with new-onset SLE. Key Points • The clinical features of new-onset SLE during pregnancy and its impact on pregnancy outcomes have rarely been reported, especially in Chinese patients. • New-onset SLE during pregnancy in Chinese women occurred primarily during the first and second trimesters and was characterised by haematological disorders, including thrombocytopaenia and anaemia. • Women with new-onset SLE during pregnancy had significantly higher disease activity scores and pregnancy loss rates than women with pre-existing SLE, especially during the first and second trimesters; controlling disease activity and prolonging gestational age may improve pregnancy outcomes in this setting.

Prevalence of autoimmune disease among pregnant women and women of reproductive age in New South Wales, Australia: a population-based study

BACKGROUND

Autoimmune diseases disproportionately affect women and have been linked to increased risk of maternal and perinatal mortality and morbidity. Our aim was to determine the prevalence of autoimmune disease among pregnant women and women of reproductive age (WRA), which is not well described.

MATERIALS AND METHODS

A population-based study was conducted using data from a survey of general practitioner (GP) encounters and state-wide hospital admissions in New South Wales (NSW). A list of 29 conditions and relevant diagnosis codes was used to identify autoimmune disease. Prevalence estimates and trends were calculated using population denominators for GP encounters for WRA in 2011-2015 and hospital admissions for WRA and pregnant women in 2013-2017.

RESULTS

A total 31,065 GP encounters for WRA were identified and 607 (2.0%) reported an autoimmune disease, equivalent to 1.1 GP encounters per 10 WRA each year when extrapolating to NSW population figures. For WRA admitted to hospital, 2.6% had an autoimmune diagnosis recorded each year equivalent to a population prevalence of 0.5%. A total 477,243 births were identified, of which 4230 mothers (0.9%) had at least one autoimmune disease recorded during a 1-year pregnancy lookback period. Autoimmune disease prevalence among both pregnant women and WRA either attending GP or hospital increased, on average, 2-4% per year over the study period.

CONCLUSIONS

A small, but potentially growing proportion of reproductive age and pregnant women have a diagnosed autoimmune disease, and this may impact their health outcomes.

Multidrug Therapy for Refractory Immune Thrombocytopenia in Pregnancy

BACKGROUND

Severe immune thrombocytopenia complicating pregnancy may require treatment beyond first-line medications (intravenous immunoglobulins or corticosteroids), but there is a paucity of literature on the use of such second-line agents in pregnancy.

CASE

The patient is a 29-year-old woman with early-onset severe immune thrombocytopenia at 13 weeks of gestation. Maternal platelet counts reached a nadir of less than 5×10/L. The thrombocytopenia persisted despite first-line medications. Romiplostim, rituximab, and azathioprine were added to the therapeutic regimen. Platelet counts eventually stabilized at greater than 150×10/L before delivery. After delivery at term, the neonate had transient B-cell suppression, which was presumed to be secondary to rituximab, but was otherwise doing well and meeting all milestones at 7 months of age.

CONCLUSION

The addition of second-line agents was associated with sustained elevation in maternal platelet counts and may have obviated the need for splenectomy.

Immune Thrombocytopenic Purpura in Pregnancy

Importance

Immune thrombocytopenia purpura (ITP), an autoimmune disease characterized by destruction of platelets, is a hematological disorder that can present in both pregnant and nonpregnant patients. Although thrombocytopenia in pregnancy can be caused by more common pathologies such as gestational thrombocytopenia and preeclampsia, ITP can present initially during pregnancy, further complicating diagnosis. Management must be considerate of both the pregnancy itself and the fetus.

Objective

Review the diagnosis, treatment, and management of ITP in pregnancy based on current recommendations.

Evidence Acquisition

Review articles, original research, and case studies were utilized.

Results

Throughout pregnancy, patients are screened for a variety of conditions or disorders of pregnancy. Thrombocytopenia is a common pathology of pregnancy, but ITP is a rare condition that a provider needs to be aware of. After ruling out secondary causes of thrombocytopenia or more common causes such as gestational thrombocytopenia or preeclampsia, ITP should be considered. After diagnosis, treatment options should be discussed and initiated to provide safety for both the mother and fetus.

Conclusions

After reading this article, the reader will understand the current recommendations regarding the diagnosis, treatment, and management of ITP in pregnancy.

Relevance

The practitioner will be comfortable treating this condition during pregnancy.

Capnocytophaga bacteremia precipitating severe thrombocytopenia and preterm labor in an asplenic host

Capnocytophaga species are gram-negative bacilli that inhabit mammalian oral surfaces and can cause opportunistic infection, especially in asplenic patients. The species Capnocytophaga canimorsus is particularly associated with dog bites and is known to cause endocarditis, meningitis, and sepsis in the general population. In pregnant patients, infections tied to Capnocytophaga species from human flora have been associated with preterm labor, chorioamnionitis, and neonatal septicemia. There is little known about the effects of zoonotically-acquired Capnocytophaga infection in pregnant patients. In this case report, we present a patient with Capnocytophaga bacteremia acquired after a dog bite associated with profound thrombocytopenia and preterm labor. Dog bites are common in the United States, and we present basic recommendations for management of dog bites in pregnant patients in order to avoid morbidity associated with delay in time to antibiotic treatment of infection as described in this case.