What are the guideline sources, guidelines and references for Thrombocytopenia in pregnancy ?
Guideline 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 American College of Obstetricians and Gynecologists (ACOG 2019), the International Consensus Report (ICR 2019), and the American Society of Hematology (ASH 2011). 1 2 3 4 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 10 /L for possible immune thrombocytopenia. B https://web.pathway.md/diseases/recLgdIWjMCgZtE5t 1/4 6/24/23, 4:06 PM Thrombocytopenia in pregnancy Pathway 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 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. Show 2 more 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 Show 2 more 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 Show 3 more As per ASH 2011 guidelines, administer either corticosteroids or IVIG in pregnant patients with immune thrombocytopenia requiring treatment. B Rituximab: consider initiating rituximab in pregnant patients with very severe immune thombocytopenia. Obtain monitoring for perinatal and neonatal immunosuppression and subsequent infection (potential complications of rituximab). C Thrombopoietin receptor agonists: consider initiating thrombopoietin-receptor agonists in late pregnancy in patients with immune thombocytopenia when other treatments have failed. C Other agents: do not use vinca alkaloids, danazol, or immunosuppressive drugs not listed in the recommendations. D https://web.pathway.md/diseases/recLgdIWjMCgZtE5t 2/4 6/24/23, 4:06 PM Thrombocytopenia in pregnancy Pathway Anti-D immunoglobulin: recognize that IV anti-D immunoglobulin in Rh(D)-positive non- splenectomized patients appears to be well tolerated and effective, however, this may potentially cause maternal or fetal hemolysis. B Analgesia: avoid using NSAIDs for postpartum or postoperative analgesia in patients with platelet counts < 70 10 /L because of increased hemorrhagic risk. D Thromboprophylaxis: initiate appropriate prophylaxis for VTE in all patients at increased risk for thromboembolism despite having immune thrombocytopenia. B Management of the fetus/neonate: avoid performing cordocentesis and fetal scalp blood sampling in the management of the fetus/neonate of a mother with immune thrombocytopenia in pregnancy. D Show 8 more 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 As per SOAP 2011 guidelines, decide on the mode of delivery in pregnant patients with immune thrombocytopenia based on obstetric indications. B Considerations for delivery: Recognize that a platelet count of 20-30 10 /L in a non-bleeding patient is safe for most pregnancies. Attempt ensuring a platelet count 50 10 /L for delivery. B Avoid performing procedures during labor that may be associated with an increased hemorrhagic risk to the fetus, specifically the use of fetal scalp electrodes, fetal blood sampling, ventouse delivery, and rotational forceps. D Neuraxial anesthesia: As per SOAP 2021 guidelines, decide on performing neuraxial procedures in patients with confirmed gestational thrombocytopenia, immune thrombocytopenia, or hypertensive disorders of pregnancy, such as preeclampsia, based on the following: avoid performing neuraxial procedures or obtain expert hematologic evaluation before proceeding with the neuraxial procedure if there are concerns for a history of bleeding associated with thrombocytopenia or DIC B consider performing the neuraxial procedure if clinically indicated if the platelet count is 70, 000 10 /L, given the low risk of spinal epidural hematoma B individualize the decision on performing a neuraxial procedure based on the risk-benefit assessment if the platelet count is 50,000-70, 000 10 /L B avoid performing neuraxial procedures if the platelet count is < 50, 000 10 /L, given the increased risk of spinal epidural hematoma compared to a platelet count 70, 000 10 /L. B Show 6 more https://web.pathway.md/diseases/recLgdIWjMCgZtE5t 3/4 6/24/23, 4:06 PM Thrombocytopenia in pregnancy Pathway As per ICR 2019 guidelines, recognize that regional axial anesthesia can be safely performed in patients with a platelet count 70 10 /L in the absence of other hemostatic abnormalities. B 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 References 1. American College of Obstetricians and Gynecologists Committee on Practice Bulletins Obstetrics in collaboration with Mark Turrentine, MD. ACOG Practice Bulletin No. 207 Thrombocytopenia in Pregnancy. Obstet Gynecol. 2019 Mar;133 3):e181-e193. Open 2. Drew Provan, Donald M Arnold, James B Bussel et al. Updated international consensus report on the investigation and management of primary immune thrombocytopenia. Blood Adv. 2019 Nov 26;3 22 3780 3817. Open 3. Neunert C, Lim W, Crowther M et al. The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood. 2011 Apr 21;117 16 4190 207. Open 4. Melissa E Bauer, Katherine Arendt, Yaakov Beilin et al. The Society for Obstetric Anesthesia and Perinatology Interdisciplinary Consensus Statement on Neuraxial Procedures in Obstetric Patients With Thrombocytopenia. Anesth Analg. 2021 Jun 1;132 6 1531 1544. Open https://web.pathway.md/diseases/recLgdIWjMCgZtE5t 4/4