Thrombocytopenia in pregnancy
- James N George, MD
James N George, MD
- Professor of Medicine
- University of Oklahoma Health Sciences Center
- Jennifer J McIntosh, DO, MS
Jennifer J McIntosh, DO, MS
- Assistant Professor of Maternal Fetal Medicine
- Medical College of Wisconsin
- Section Editors
- Lawrence LK Leung, MD
Lawrence LK Leung, MD
- Editor-in-Chief — Hematology
- Section Editor — Disorders of Hemostasis and Coagulation
- Professor of Medicine
- Stanford University School of Medicine
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- Deputy Editors
- Jennifer S Tirnauer, MD
Jennifer S Tirnauer, MD
- Deputy Editor — Hematology
- Vanessa A Barss, MD, FACOG
Vanessa A Barss, MD, FACOG
- Senior Deputy Editor — UpToDate
- Deputy Editor — Obstetrics, Gynecology and Women's Health
- Associate Clinical Professor of Obstetrics, Gynecology and Reproductive Biology
- Harvard Medical School
Evaluation and management of thrombocytopenia during pregnancy and postpartum may be challenging because there are many potential causes, some directly related to the pregnancy and some unrelated. For many of the causes there are no diagnostic laboratory tests. Management options may have the potential for serious complications for both mother and fetus and may require urgent decisions about delivery, and there may be concerns about fetal thrombocytopenia.
This topic reviews our approaches to determining the cause of thrombocytopenia in a pregnant woman and to management during pregnancy and delivery, which in some cases cannot wait for full diagnostic evaluation.
Additional information on the diagnosis and management of specific conditions that cause thrombocytopenia is presented in more detail separately:
●Immune thrombocytopenia (ITP) – (See "Immune thrombocytopenia (ITP) in adults: Clinical manifestations and diagnosis".)
●Drug-induced thrombocytopenia – (See "Drug-induced immune thrombocytopenia".)
- Sejeny SA, Eastham RD, Baker SR. Platelet counts during normal pregnancy. J Clin Pathol 1975; 28:812.
- Fay RA, Hughes AO, Farron NT. Platelets in pregnancy: hyperdestruction in pregnancy. Obstet Gynecol 1983; 61:238.
- Verdy E, Bessous V, Dreyfus M, et al. Longitudinal analysis of platelet count and volume in normal pregnancy. Thromb Haemost 1997; 77:806.
- Boehlen F, Hohlfeld P, Extermann P, et al. Platelet count at term pregnancy: a reappraisal of the threshold. Obstet Gynecol 2000; 95:29.
- Burrows RF, Kelton JG. Thrombocytopenia at delivery: a prospective survey of 6715 deliveries. Am J Obstet Gynecol 1990; 162:731.
- Sainio S, Kekomäki R, Riikonen S, Teramo K. Maternal thrombocytopenia at term: a population-based study. Acta Obstet Gynecol Scand 2000; 79:744.
- Myers B. Diagnosis and management of maternal thrombocytopenia in pregnancy. Br J Haematol 2012; 158:3.
- Gernsheimer T, James AH, Stasi R. How I treat thrombocytopenia in pregnancy. Blood 2013; 121:38.
- American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics. Practice Bulletin No. 166: Thrombocytopenia in Pregnancy. Obstet Gynecol 2016; 128:e43.
- Parnas M, Sheiner E, Shoham-Vardi I, et al. Moderate to severe thrombocytopenia during pregnancy. Eur J Obstet Gynecol Reprod Biol 2006; 128:163.
- Aster RH. "Gestational" thrombocytopenia: a plea for conservative management. N Engl J Med 1990; 323:264.
- Jaschevatzky OE, David H, Bivas M, et al. Outcome of pregnancies associated with marked gestational thrombocytopenia. J Perinat Med 1994; 22:351.
- Letsky EA, Greaves M. Guidelines on the investigation and management of thrombocytopenia in pregnancy and neonatal alloimmune thrombocytopenia. Maternal and Neonatal Haemostasis Working Party of the Haemostasis and Thrombosis Task Force of the British Society for Haematology. Br J Haematol 1996; 95:21.
- Burrows RF, Kelton JG. Fetal thrombocytopenia and its relation to maternal thrombocytopenia. N Engl J Med 1993; 329:1463.
- George JN, Woolf SH, Raskob GE, et al. Idiopathic thrombocytopenic purpura: a practice guideline developed by explicit methods for the American Society of Hematology. Blood 1996; 88:3.
- Terrell DR, Beebe LA, Vesely SK, et al. The incidence of immune thrombocytopenic purpura in children and adults: A critical review of published reports. Am J Hematol 2010; 85:174.
- Moise KJ Jr. Autoimmune thrombocytopenic purpura in pregnancy. Clin Obstet Gynecol 1991; 34:51.
- Webert KE, Mittal R, Sigouin C, et al. A retrospective 11-year analysis of obstetric patients with idiopathic thrombocytopenic purpura. Blood 2003; 102:4306.
- American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013; 122:1122.
- McMinn JR, George JN. Evaluation of women with clinically suspected thrombotic thrombocytopenic purpura-hemolytic uremic syndrome during pregnancy. J Clin Apher 2001; 16:202.
- Moatti-Cohen M, Garrec C, Wolf M, et al. Unexpected frequency of Upshaw-Schulman syndrome in pregnancy-onset thrombotic thrombocytopenic purpura. Blood 2012; 119:5888.
- Jiang Y, McIntosh JJ, Reese JA, et al. Pregnancy outcomes following recovery from acquired thrombotic thrombocytopenic purpura. Blood 2014; 123:1674.
- Fakhouri F, Roumenina L, Provot F, et al. Pregnancy-associated hemolytic uremic syndrome revisited in the era of complement gene mutations. J Am Soc Nephrol 2010; 21:859.
- Amorosi EL, Ultmann JE. Thrombotic thrombocytopenic purpura: Report of 16 cases and review of the literature. Medicine (Baltimore) 1966; 45:139.
- Scully M, Thomas M, Underwood M, et al. Thrombotic thrombocytopenic purpura and pregnancy: presentation, management, and subsequent pregnancy outcomes. Blood 2014; 124:211.
- Martin JN Jr, Bailey AP, Rehberg JF, et al. Thrombotic thrombocytopenic purpura in 166 pregnancies: 1955-2006. Am J Obstet Gynecol 2008; 199:98.
- Mannucci PM, Canciani MT, Forza I, et al. Changes in health and disease of the metalloprotease that cleaves von Willebrand factor. Blood 2001; 98:2730.
- Provan D, Stasi R, Newland AC, et al. International consensus report on the investigation and management of primary immune thrombocytopenia. Blood 2010; 115:168.
- Neunert C, Lim W, Crowther M, et al. The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood 2011; 117:4190.
- www.ouhsc.edu/platelets (Accessed on March 01, 2011).
- George JN, Nester CM, McIntosh JJ. Syndromes of thrombotic microangiopathy associated with pregnancy. Hematology Am Soc Hematol Educ Program 2015; 2015:644.
- Martin JN Jr, Files JC, Blake PG, et al. Postpartum plasma exchange for atypical preeclampsia-eclampsia as HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. Am J Obstet Gynecol 1995; 172:1107.
- Martí-Carvajal AJ, Peña-Martí GE, Comunián-Carrasco G. Medical treatments for idiopathic thrombocytopenic purpura during pregnancy. Cochrane Database Syst Rev 2009; :CD007722.
- Christiaens GC, Nieuwenhuis HK, von dem Borne AE, et al. Idiopathic thrombocytopenic purpura in pregnancy: a randomized trial on the effect of antenatal low dose corticosteroids on neonatal platelet count. Br J Obstet Gynaecol 1990; 97:893.
- Sun D, Shehata N, Ye XY, et al. Corticosteroids compared with intravenous immunoglobulin for the treatment of immune thrombocytopenia in pregnancy. Blood 2016; 128:1329.
- van Runnard Heimel PJ, Schobben AF, Huisjes AJ, et al. The transplacental passage of prednisolone in pregnancies complicated by early-onset HELLP syndrome. Placenta 2005; 26:842.
- Rodeghiero F, Stasi R, Gernsheimer T, et al. Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. Blood 2009; 113:2386.
- Palmeira P, Quinello C, Silveira-Lessa AL, et al. IgG placental transfer in healthy and pathological pregnancies. Clin Dev Immunol 2012; 2012:985646.
- DeSesso JM, Williams AL, Ahuja A, et al. The placenta, transfer of immunoglobulins, and safety assessment of biopharmaceuticals in pregnancy. Crit Rev Toxicol 2012; 42:185.
- Chakravarty EF, Murray ER, Kelman A, Farmer P. Pregnancy outcomes after maternal exposure to rituximab. Blood 2011; 117:1499.
- Simon L, Santi TM, Sacquin P, Hamza J. Pre-anaesthetic assessment of coagulation abnormalities in obstetric patients: usefulness, timing and clinical implications. Br J Anaesth 1997; 78:678.
- Bernstein J, Hua B, Kahana M, et al. Neuraxial Anesthesia in Parturients with Low Platelet Counts. Anesth Analg 2016; 123:165.
- Goodier CG, Lu JT, Hebbar L, et al. Neuraxial Anesthesia in Parturients with Thrombocytopenia: A Multisite Retrospective Cohort Study. Anesth Analg 2015; 121:988.
- van Veen JJ, Nokes TJ, Makris M. The risk of spinal haematoma following neuraxial anaesthesia or lumbar puncture in thrombocytopenic individuals. Br J Haematol 2010; 148:15.
- Ruggeri M, Schiavotto C, Castaman G, et al. Gestational thrombocytopenia: a prospective study. Haematologica 1997; 82:341.
- Payne SD, Resnik R, Moore TR, et al. Maternal characteristics and risk of severe neonatal thrombocytopenia and intracranial hemorrhage in pregnancies complicated by autoimmune thrombocytopenia. Am J Obstet Gynecol 1997; 177:149.
- Asano T, Sawa R, Araki T, Yamamoto M. Incidence of thrombocytopenia in infants born to mothers with idiopathic thrombocytopenic purpura. Acta Paediatr Jpn 1998; 40:112.
- Iyori H, Fujisawa K, Akatsuka J. Thrombocytopenia in neonates born to women with autoimmune thrombocytopenic purpura. Pediatr Hematol Oncol 1997; 14:367.
- Valat AS, Caulier MT, Devos P, et al. Relationships between severe neonatal thrombocytopenia and maternal characteristics in pregnancies associated with autoimmune thrombocytopenia. Br J Haematol 1998; 103:397.
- Christiaens GC, Nieuwenhuis HK, Bussel JB. Comparison of platelet counts in first and second newborns of mothers with immune thrombocytopenic purpura. Obstet Gynecol 1997; 90:546.
- Burrows RF, Kelton JG. Pregnancy in patients with idiopathic thrombocytopenic purpura: assessing the risks for the infant at delivery. Obstet Gynecol Surv 1993; 48:781.
- Yamada H, Kato EH, Kishida T, et al. Risk factors for neonatal thrombocytopenia in pregnancy complicated by idiopathic thrombocytopenic purpura. Ann Hematol 1998; 76:211.
- Cook RL, Miller RC, Katz VL, Cefalo RC. Immune thrombocytopenic purpura in pregnancy: a reappraisal of management. Obstet Gynecol 1991; 78:578.
- Samuels P, Bussel JB, Braitman LE, et al. Estimation of the risk of thrombocytopenia in the offspring of pregnant women with presumed immune thrombocytopenic purpura. N Engl J Med 1990; 323:229.
- Fujimura K, Harada Y, Fujimoto T, et al. Nationwide study of idiopathic thrombocytopenic purpura in pregnant women and the clinical influence on neonates. Int J Hematol 2002; 75:426.
- Koyama S, Tomimatsu T, Kanagawa T, et al. Reliable predictors of neonatal immune thrombocytopenia in pregnant women with idiopathic thrombocytopenic purpura. Am J Hematol 2012; 87:15.
- Paidas MJ, Berkowitz RL, Lynch L, et al. Alloimmune thrombocytopenia: fetal and neonatal losses related to cordocentesis. Am J Obstet Gynecol 1995; 172:475.
- Anteby E, Shalev O. Clinical relevance of gestational thrombocytopenia of < 100,000/microliters. Am J Hematol 1994; 47:118.
- Fujimura Y, Matsumoto M, Kokame K, 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; 144:742.
- DEFINITION AND INCIDENCE
- LIST OF CAUSES
- Gestational thrombocytopenia (GT)
- Preeclampsia with severe features/HELLP
- Acute fatty liver of pregnancy
- Thrombotic microangiopathy (TMA)
- - TTP
- - Complement-mediated TMA
- - ST-HUS
- Causes of thrombocytopenia not triggered by the pregnancy
- DETERMINING THE LIKELY CAUSE(S)
- Overview of the evaluation
- Isolated, asymptomatic thrombocytopenia; platelets >80,000
- Acutely ill, platelets <80,000, bleeding, thrombosis, or other major findings
- MANAGEMENT DECISIONS
- Treatment of bleeding or severe thrombocytopenia
- Frequency of platelet count monitoring
- Need for urgent/emergent delivery
- - Conditions treated by delivery
- - Conditions not treated by delivery
- Need for plasma exchange or anti-complement therapy
- Need for other medications
- - ITP therapies
- - Anticoagulation for HIT
- - Antibiotics
- Neuraxial anesthesia
- Neonatal testing
- Recurrence in future pregnancies
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS