Download PDF
CC BY 4.0 · Rev Bras Ginecol Obstet 2020; 42(12): 834-840
DOI: 10.1055/s-0040-1721350
Review Article

Update on Thrombocytopenia in Pregnancy

Atualização sobre trombocitopenia na gravidez
Simone Filipa Carrasqueira Subtil 
1   Universidade de Coimbra, Coimbra, Portugal
,
Jorge Miguel Bastos Mendes 
1   Universidade de Coimbra, Coimbra, Portugal
,
Ana Luísa Fialho de Amaral Areia 
1   Universidade de Coimbra, Coimbra, Portugal
,
José Paulo Achando Silva Moura 
1   Universidade de Coimbra, Coimbra, Portugal
› Author Affiliations
› Further Information
   Permissions and Reprints

Abstract

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.

Resumo

Trombocitopenia, definida como uma contagem de plaquetária < 150.000 mm3, é frequentemente diagnosticada pelos obstetras, uma vez que este parâmetro está incluído na vigilância de rotina durante a gravidez, com uma incidência de entre 7 e 12%. Assim, decisões relativas à avaliação e orientação subsequentes são primordiais. Embora a maioria dos casos ocorra devido a alterações fisiológicas, como a trombocitopenia gestacional, outras causas podem estar relacionadas com condições graves que podem levar à morte fetal ou materna. Distinguir entre estas entidades pode ser desafiante: elas podem ser específicas da gravidez (pré-eclâmpsia/síndrome HELLP [hemolysis, elevated liver enzymes, low platelets]) ou não (púrpura trombocitopênica imune, púrpura trombocitopênica trombótica ou síndrome hemolítico urêmico). Compreender os mecanismos e reconhecer os sinais e sintomas é essencial para decidir uma adequada linha de investigação. A severidade da trombocitopenia, a sua etiologia e a idade gestacional ditam regimes de tratamento diferentes.

Keywords

thrombocytopenia - pregnancy - preeclampsia - HELLP syndrome - thrombotic microangiopathy

Palavras-chave

trombocitopenia - gravidez - pré-eclâmpsia - síndrome HELLP - microangiopatia trombótica


Publication History

Received: 24 March 2020

Accepted: 22 September 2020

Article published online:
21 December 2020

© 2020. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

Thieme Revinter Publicações Ltda.
Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil

 

  • References

  • 1 Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin no. 207: thrombocytopenia in pregnancy. Obstet Gynecol 2019; 133 (03) e181-e193
    CrossrefPubMedSearch in Google Scholar
  • 2 Baucom AM, Kuller JA, Dotters-Katz S. Immune thrombocytopenic purpura in pregnancy. Obstet Gynecol Surv 2019; 74 (08) 490-496
    CrossrefPubMedSearch in Google Scholar
  • 3 Myers B. Review thrombocytopenia in pregnancy. Obstet Gynaecol 2009; 11: 177-183
    CrossrefPubMedSearch in Google Scholar
  • 4 Zainal A, Salama A, Alweis R. Immune thrombocytopenic purpura. J Community Hosp Intern Med Perspect 2019; 9 (01) 59-61
    CrossrefPubMedSearch in Google Scholar
  • 5 Rajasekhar A, Gernsheimer T, Stasi R, James AH. 2013 clinical practice guide on thrombocytopenia in pregnancy. Washington (DC): American Society of Hematology; 2013
    Search in Google Scholar
  • 6 Reese JA, Peck JD, Deschamps DR, McIntosh JJ, Knudtson EJ, Terrell DR. et al. Platelet counts during pregnancy. N Engl J Med 2018; 379 (01) 32-43
    CrossrefPubMedSearch in Google Scholar
  • 7 Provan D, Arnold DM, Bussel JB, Chong BH, Cooper N, Gernsheimer T. et al. Updated international consensus report on the investigation and management of primary immune thrombocytopenia. Blood Adv 2019; 3 (22) 3780-3817
    CrossrefPubMedSearch in Google Scholar
  • 8 Eslick R, McLintock C. Managing ITP and thrombocytopenia in pregnancy. Platelets 2020; 31 (03) 300-306
    CrossrefPubMedSearch in Google Scholar
  • 9 Valera MC, Parant O, Vayssiere C, Arnal JF, Payrastre B. Physiologic and pathologic changes of platelets in pregnancy. Platelets 2010; 21 (08) 587-595
    CrossrefPubMedSearch in Google Scholar
  • 10 Cines DB, Levine LD. Thrombocytopenia in pregnancy. Blood 2017; 130 (21) 2271-2277
    CrossrefPubMedSearch in Google Scholar
  • 11 Rottenstreich A, Israeli N, Levin G, Rottenstreich M, Elchalal U, Kalish Y. Clinical characteristics, neonatal risk and recurrence rate of gestational thrombocytopenia with platelet count <100 × 109/L. Eur J Obstet Gynecol Reprod Biol 2018; 231: 75-79
    CrossrefPubMedSearch in Google Scholar
  • 12 Ciobanu AM, Colibaba S, Cimpoca B, Peltecu G, Panaitescu AM. Thrombocytopenia in Pregnancy. Maedica (Bucur) 2016; 11 (01) 55-60
    PubMedSearch in Google Scholar
  • 13 Wisner K. Gestational hypertension and preeclampsia. MCN Am J Matern Child Nurs 2019; 44 (03) 170
    CrossrefPubMedSearch in Google Scholar
  • 14 Woudstra DM, Chandra S, Hofmeyr GJ, Dowswell T. Corticosteroids for HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome in pregnancy. Cochrane Database Syst Rev 2010; (09) CD008148
    CrossrefPubMedSearch in Google Scholar
  • 15 Neave L, Scully M. Microangiopathic hemolytic anemia in pregnancy. Transfus Med Rev 2018; 32 (04) 230-236
    CrossrefPubMedSearch in Google Scholar
  • 16 Brown MA, Magee LA, Kenny LC, Karumanchi SA, McCarthy FP, Saito S. et al; International Society for the Study of Hypertension in Pregnancy (ISSHP). Hypertensive disorders of pregnancy: ISSHP classification, diagnosis, and management recommendations for international practice. Hypertension 2018; 72 (01) 24-43
    CrossrefPubMedSearch in Google Scholar
  • 17 Thomas MR, Robinson S, Scully MA. How we manage thrombotic microangiopathies in pregnancy. Br J Haematol 2016; 173 (06) 821-830
    CrossrefPubMedSearch in Google Scholar
  • 18 Ding J, Han LP, Lou XP, Geng LN, Liu D, Yang Q. et al. Effectiveness of combining plasma exchange with plasma perfusion in acute fatty liver of pregnancy: a retrospective analysis. Gynecol Obstet Invest 2015; 79 (02) 97-100
    CrossrefPubMedSearch in Google Scholar
  • 19 Khaspekova SG, Shustova ON, Golubeva NV, Naimushin YA, Larina LE, Mazurov AV. Circulating antiplatelet antibodies in pregnant women with immune thrombocytopenic purpura as predictors of thrombocytopenia in the newborns. Platelets 2019; 30 (08) 1008-1012
    CrossrefPubMedSearch in Google Scholar
  • 20 Loustau V, Debouverie O, Canoui-Poitrine F, Baili L, Khellaf M, Toubul C. et al. Effect of pregnancy on the course of immune thrombocytopenia: a retrospective study of 118 pregnancies in 82 women. Br J Haematol 2014; 166 (06) 929-935
    CrossrefPubMedSearch in Google Scholar
  • 21 Care A, Pavord S, Knight M, Alfirevic Z. Severe primary autoimmune thrombocytopenia in pregnancy: a national cohort study. BJOG 2018; 125 (05) 604-612
    CrossrefPubMedSearch in Google Scholar
  • 22 Sun D, Shehata N, Ye XY, Gregorovich S, de France B, Arnold DM. et al. Corticosteroids compared with intravenous immunoglobulin for the treatment of immune thrombocytopenia in pregnancy. Blood 2016; 128 (10) 1329-1335
    CrossrefPubMedSearch in Google Scholar
  • 23 Rosa María RN, Laura RL, Ángeles PB, Laura LB. Use of Romiplostim during pregnancy as a rescue therapy in primary immune thrombocytopenia: Literature review and case description. Platelets 2020; 31 (03) 403-406
    CrossrefPubMedSearch in Google Scholar
  • 24 Ferreira IJMCF, Sousa F, Vasco EM, Areia ALFA, Moura JPAS, Carda J, Ribeiro L. Severe immune thrombocytopenia in pregnancy treated with Eltrombopag - A case report. J Gynecol Obstet Hum Reprod 2018; 47 (08) 405-408
    CrossrefPubMedSearch in Google Scholar
  • 25 Gupta M, Govindappagari S, Burwick RM. Pregnancy-associated atypical hemolytic uremic syndrome: a systematic review. Obstet Gynecol 2020; 135 (01) 46-58
    CrossrefPubMedSearch in Google Scholar
  • 26 Scully M, Thomas M, Underwood M, Watson H, Langley K, Camilleri RS. et al; collaborators of the UK TTP Registry. Thrombotic thrombocytopenic purpura and pregnancy: presentation, management, and subsequent pregnancy outcomes. Blood 2014; 124 (02) 211-219
    CrossrefPubMedSearch in Google Scholar
  • 27 Bruel A, Kavanagh D, Noris M, Delmas Y, Wong EKS, Bresin E. et al. Hemolytic uremic syndrome in pregnancy and postpartum. Clin J Am Soc Nephrol 2017; 12 (08) 1237-1247
    CrossrefPubMedSearch in Google Scholar
  • 28 Fujimura Y, Matsumoto M, Kokame K, Isonishi A, Soejima K, Akuyama N. et al. Pregnancy-induced thrombocytopenia and TTP, and the risk of fetal death, in Upshaw-Schulman syndrome: a series of 15 pregnancies in 9 genotyped patients. Br J Haematol 2009; 144 (05) 742-754
    CrossrefPubMedSearch in Google Scholar
  • 29 Sacerdoti F, Scalise ML, Burdet J, Amaral MM, Franchi AM, Ibarra C. Shiga toxin-producing escherichia coli infections during pregnancy. Microorganisms 2018; 6 (04) 111
    CrossrefPubMedSearch in Google Scholar
  • 30 Kozlovskaya NL, Korotchaeva YV, Bobrova LA. Adverse outcomes in obstetric-atypical haemolytic uraemic syndrome: a case series analysis. J Matern Fetal Neonatal Med 2019; 32 (17) 2853-2859
    CrossrefPubMedSearch in Google Scholar
  • 31 Sharma R, Keyzner A, Liu J, Bradley T, Allen SL. Successful pregnancy outcome in paroxysmal nocturnal hemoglobinuria (PNH) following escalated eculizumab dosing to control breakthrough hemolysis. Leuk Res Rep 2015; 4 (01) 36-38
    CrossrefPubMedSearch in Google Scholar
  • 32 Sammaritano LR. Antiphospholipid syndrome. Best Pract Res Clin Rheumatol 2020; 34 (01) 101463
    CrossrefPubMedSearch in Google Scholar
  • 33 Funke A, Danowski A, de Andrade DCO, Rêgo J, Levy RA. A importância de reconhecer a síndrome antifosfolípide na medicina vascular. J Vasc Bras 2017; 16 (02) 140-149
    CrossrefPubMedSearch in Google Scholar
  • 34 Govindappagari S, Nguyen M, Gupta M, Hanna RM, Burwick RM. Severe vitamin B12 deficiency in pregnancy mimicking HELLP syndrome. Case Rep Obstet Gynecol 2019; 2019: 4325647
    CrossrefPubMedSearch in Google Scholar
  • 35 Peitsidis P, Datta T, Pafilis I, Otomewo O, Tuddenham EGD, Kadir RA. Bernard Soulier syndrome in pregnancy: a systematic review. Haemophilia 2010; 16 (04) 584-591
    CrossrefPubMedSearch in Google Scholar
  • 36 Wijemanne A, Watt-Coote I, Austin S. Glanzmann thrombasthenia in pregnancy: Optimising maternal and fetal outcomes. Obstet Med 2016; 9 (04) 169-170
    CrossrefPubMedSearch in Google Scholar