Year : 2020 | Volume
: 7 | Issue : 3 | Page : 155--157
Immune thrombocytopenic purpura in pregnancy
Narayani Kalnawat, Archana Chatterji
Department of Obstetrics and Gynaecology, MGM Medical College & Hospital, Navi Mumbai, Maharashtra, India
Dr. Narayani Kalnawat
Department of Obstetrics and Gynaecology, MGM Medical College & Hospital, Kamothe, Navi Mumbai, Maharashtra.
We present a case of a 27-year-old primigravida, a known case of immune thrombocytopenic purpura (ITP), who is presented in our outpatient department in latent labor at 36 weeks of gestation with platelet count 36,000/µL. She has been on prednisolone since the first trimester and has a history of platelet transfusion at 28 weeks of gestation. She was given platelet transfusions during labor, and delivered vaginally a male baby with an appearance, pulse, grimace, activity, and respiration score of 8/10 and 10/10 with normal platelet counts at birth and 24h later. She was discharged on the 7th postnatal day. The aim of this case report was to discuss ITP in pregnancy, its clinical presentation, and management.
|How to cite this article:|
Kalnawat N, Chatterji A. Immune thrombocytopenic purpura in pregnancy.MGM J Med Sci 2020;7:155-157
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Kalnawat N, Chatterji A. Immune thrombocytopenic purpura in pregnancy. MGM J Med Sci [serial online] 2020 [cited 2020 Oct 30 ];7:155-157
Available from: http://www.mgmjms.com/text.asp?2020/7/3/155/292379
Immune thrombocytopenic purpura (ITP), a bleeding disorder characterized by low platelet count, is not associated with any systemic disease. The primary form, known as idiopathic thrombocytopenic purpura, is usually caused by a cluster of immunoglobulin G (IgG) antibodies directed against one or more platelet glycoproteins.
Primary immune thrombocytopenia occurs in adults aged 30–60 years, more commonly in women. The incidence of ITP in pregnancy is about 1–2/1000. ITP accounts for less than 5% of all thrombocytopenic pregnant patients. The treatment has been recommended for women with a platelet count below 10,000/μL at any time during pregnancy or below 30,000/μL in the second or third trimester or when associated with bleeding. Owing to the low incidence of severe neonatal thrombocytopenia and morbidity, fetal platelet determination and cesarean delivery only for fetal indications are not recommended.
Most women with ITP have normal findings on physical examination (splenomegaly is absent) and purpura may be present especially in the lower limb. Newborns have normal findings on physical examinations, no cephalohematoma, or ecchymoses over the presenting part, and no purpura. The most important fetal or neonatal complication of ITP in pregnancy is “fetal or neonatal alloimmune thrombocytopenia.”
A 27-year-old primigravida, who was conceived through intrauterine insemination (IUI), was presented to our hospital at 36 weeks of gestation with complaints of bleeding per vaginum. She was a known case of ITP for 1 year and was on prednisolone 20 mg twice daily.
Upon examination, she was vitally stable, had uterine contractions, and was in latent labor. On per speculum examination, she did not have any active bleeding or other external bleeding manifestations and had no history of bleeding gums, menorrhagia, or purpuric spots before pregnancy. She was admitted to another hospital for fever at 28 weeks of gestation when her platelet count dropped to 17,000/µL and she was given platelet transfusion. She was discharged after 1 week, with platelet count 86,000/µL.
She was admitted for intrapartum monitoring and delivery. On hematological examination, her hemoglobin (Hb) was 12.6 and platelet count was 26,000/µL. Peripheral smear showed normocytic normochromic picture. Liver enzymes as well as serum lactate dehydrogenase were elevated. Bleeding time, clotting time and prothrombin time/international normalized ratio were normal. She was given a platelet transfusion as delivery was imminent.
She delivered vaginally a healthy male baby weighing 2.9kg with appearance, pulse, grimace, activity, and respiration scores of 8/10 and 10/10. The baby was kept in the Neonatal Intensive Care Unit (NICU) for observation. She was given Inj. Hydrocortisone 100 mg immediately after delivery. Postpartum blood loss was around 800mL, but hemostasis was achieved with uterotonics. She was monitored closely and had mild tachycardia but was otherwise vitally stable. Two hemograms were done for the neonate, 24h apart, which was normal. Her complete blood count repeated 12 hourly and the platelet count had dropped from 56,000/µL immediately after delivery to 40,000/µL on 2nd postnatal days. Hb had also been reduced to 7.9 for which she was given a packed red cell transfusion. She was then shifted to the intensive care unit for observation. During this period, oral prednisolone continued. An abdominal ultrasound was done in view of elevated liver enzymes, which revealed no abnormalities.
Her Haemogram was repeated after 12h and showed a rising trend in platelet count and hemoglobin from post-natal day 3. Liver enzymes also returned to the normal range spontaneously. She was discharged on postnatal day 7 with platelet count 1,50,000/µL and Hb 9.6.
Pregnant women with ITP can be asymptomatic or may present with a history of easy bruisability, bleeding into the mucous membranes (epistaxis or gingival bleeding), or purpura. ITP occurs in all races and is more common in females than males (ratio 3:1) especially in women of childbearing age (second and third decades of life), with an incident of 1–2 in 1000 pregnancies. They may have a history of menorrhagia or menometrorrhagia prior to pregnancy, a history of delivering the term newborn with thrombocytopenia, visceral or intracranial hemorrhage, or spontaneous or prolonged bleeding after venipuncture.
The treatment of ITP is different for pregnant versus nonpregnant women. Complications in pregnancy and fetal development may occur due to the drugs and their side effects. Glucocorticoids are considered for initial therapy in uncomplicated cases. Vaginal delivery can be performed with a platelet count above 50 × 109/L. Platelet count should be raised to 80 × 109/L if a cesarean section is considered. Platelet count of less than 30 × 109/L requires platelet transfusions to prevent maternal bleeding during labor. Instrumental delivery is not recommended due to the possibility of fetal thrombocytopenia leading to cephalhematoma formation or intracranial hemorrhage.
Immune thrombocytopenic purpura is caused by antiplatelet antibodies called platelet-associated immunoglobulin (PAIg), which bind to glycoprotein (GP) IIb–IIIa complex or GP1b/IX complex or other glycoprotein complexes. These antibody-coated platelets are destroyed by tissue macrophages located primarily in the spleen. A marked reduction in platelet production was also observed in acute and chronic ITP since autoantibodies against this platelet glycoprotein interfere with megakaryocytic maturation. The most common condition confused with ITP is gestational thrombocytopenia, which occurs in 4.8% of the pregnancies. Gestational thrombocytopenia is likely when an otherwise healthy woman with a previously documented normal platelet count develops mild thrombocytopenia with a platelet count between 70,000/μL and 100,000/μL in the third trimester of an uncomplicated pregnancy. ITP generally causes moderate-to-severe thrombocytopenia in the first trimester. ITP may exacerbate during pregnancy but, generally, the platelet count returns to the prepregnancy level after delivery.
While treating ITP during pregnancy, a multidisciplinary approach should be adopted to manage the mother and fetus with the help of a hematologist, an obstetrician, and a neonatologist. The duration of ITP may be important for determining the risk of complications. Thrombocytopenia attributed to aplastic anemia or myelodysplasia was associated with a 53.8% premature birth compared with incidental thrombocytopenia in pregnancy (11.3%) and ITP (16.7%). Hydrocephalus can occur as a rare complication of intracranial hemorrhage in fetuses born to mothers with ITP.
ITP is a diagnosis of exclusion, and many differential diagnoses may complicate it. Gestational or “incidental” thrombocytopenia remains the most common cause of thrombocytopenia in pregnancy. It may be impossible to distinguish it from mild ITP. However, ITP may be associated with adverse maternal and fetal outcomes, while gestational thrombocytopenia is generally not.
Early diagnosis is of utmost importance in treating such patients. Close monitoring of platelet counts during pregnancy can prevent most maternal and fetal complications. ITP is not an indication per se for cesarean section. A multidisciplinary approach along with the availability of intensive care for the mother and neonate reduces morbidity and mortality considerably.
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Conflicts of interest
There are no conflicts of interest.
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