The American College of Obstetricians and Gynecologists (ACOG) has issued a practice bulletin on thrombocytopenia in pregnant women, offering clinical considerations and recommendations. They include:
• Maternal thrombocytopenia between 100 x 109/L and 149 x 109/L in asymptomatic pregnant women with no history of bleeding problems is usually due to gestational thrombocytopenia.
• Given the very low risk of serious neonatal hemorrhage, the mode of delivery in pregnancies complicated with ITP should be determined based upon obstetric considerations alone.
• In pregnancies defined as “high risk” of intracranial hemorrhage (fetal platelet counts by umbilical cord blood sampling at 20 weeks of gestation of less than 20 x 109/L or a sibling with a perinatal intracranial hemorrhage), maternal IVIG combined with prednisone is more effective than IVIG alone in eliciting a satisfactory fetal platelet response. Whereas in “standard risk” pregnancies (no history of intracranial hemorrhage in a previously affected sibling and initial fetal platelet counts greater than 20 x 109/L at 20 weeks of gestation), IVIG or prednisone therapy is beneficial, with no significant advantage of one therapy over another.
• Consensus guidelines recommend platelet transfusion to increase the maternal platelet count to more than 50 x 109/L before major surgery.
• Epidural or spinal anesthesia is considered acceptable in patients with platelet counts greater than or equal to 80 x 109/L provided that the platelet level is stable, there is no other acquired or congenital coagulopathy, the platelet function is normal, and the patient is not on any antiplatelet or anticoagulant therapy.
• Fetal–neonatal alloimmune thrombocytopenia should be suspected in cases of otherwise unexplained fetal or neonatal thrombocytopenia, hemorrhage, or ultrasonographic findings consistent with intracranial bleeding.
Citation: American College of Obstetricians and Gynecologists. Thrombocytopenia in pregnancy. Practice Bulletin No. 166. Obstet Gynecol. 2016;128:e43–53.