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Thrombocytopenia in pregnancy

Key sources
The following summarized guidelines for the evaluation and management of thrombocytopenia in pregnancy are prepared by our editorial team based on guidelines from the Society for Obstetric Anesthesia and Perinatology (SOAP 2021), the International Consensus Report (ICR 2019), the American College of Obstetricians and Gynecologists (ACOG 2019), and the American Society of Hematology (ASH 2011).
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Guidelines

1.Screening and diagnosis

Diagnosis
As per ICR 2019 guidelines:
Evaluate pregnant patients with a history suggestive of immune thrombocytopenia or with a platelet count < 80×10⁹/L for possible immune thrombocytopenia.
B
Diagnose immune thrombocytopenia based on the exclusion of other competing conditions, as in non-pregnant patients, using the patient's history, physical examination, blood counts, and blood smear examination.
B
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2.Classification and risk stratification

Prediction of neonatal thrombocytopenia: recognize that patients with a previous newborn, thrombocytopenic or not, are likely to have a second baby with a similar platelet count.
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3.Diagnostic investigations

Laboratory testing: obtain laboratory evaluation in pregnant patients with suspected immune thrombocytopenia similar to the non-pregnant patients but with special consideration given to rule out hypertensive, microangiopathic, coagulopathic and hepatic disorders associated with pregnancy. Obtain testing based on the clinical features and consider including a review of the blood smear, reticulocyte count, coagulation screen, liver function, thyroid function, antinuclear antibodies, and antiphospholipid antibodies.
B
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4.Diagnostic procedures

Bone marrow biopsy: do not perform bone marrow examination unless there are atypical features.
D

5.Medical management

Corticosteroids and IVIg: as per ICR 2019 guidelines, initiate oral corticosteroids or IVIG as first-line therapy in pregnant patients with immune thrombocytopenia.
B
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More topics in this section

  • Rituximab

  • Thrombopoietin receptor agonists

  • Other agents

  • Anti-D immunoglobulin

  • Analgesia

  • Thromboprophylaxis

  • Management of the fetus/neonate

6.Therapeutic procedures

Mode of delivery: as per ICR 2019 guidelines, determine the mode of delivery based on obstetric indications and not by anticipation of the neonatal platelet count.
B

More topics in this section

  • Considerations for delivery

  • Neuraxial anesthesia

7.Surgical interventions

Splenectomy
Perform splenectomy in the second trimester in the rare instances when it is required.
B
Recognize that previous splenectomy has been associated with worsening of maternal immune thrombocytopenia in pregnancy
B
and a higher risk for neonatal thrombocytopenia.
B

8.Patient education

General counseling: provide pre-pregnancy counseling to female patients with immune thrombocytopenia contemplating pregnancy.
B

9.Follow-up and surveillance

Observation: observe patients with a rapidly falling platelet count more closely than patients with low but stable levels.
B