| Fact | Explanation |
|---|---|
| Asymptomatic [1] [2] [3] [4] [5] [6] [7] | Pregnant women with ITP can be asymptomatic and maybe diagnosed at routine investigations [1] [2] [3] [4] [5] [6] [7] |
| Easy bruisability, petechiae ( purple-red rash) [1] [2] [3] [4] [5] [6] [7] | They may complain of easy bruisabilty in skin following trauma or spontaneously. Also a rash (Petechiae) may also be a complaint. This is due to low platelet count. [1] [2] [3] [4] [5] [6] [7] |
| Mucosal bleeding such as epistaxis or gingival bleeding [1] [2] [3] [4] [5] [6] [7] | Low platelet count may cause bleeding into mucosal membranes therefore, nasal bleeding, gum bleeding are frequent complaints [1] [2] [3] [4] [5] [6] [7] |
| Menorrhagia prior to pregnancy or post partum hemorrhage in previous deliveries [1] [2] [3] [4] [5] [6] [7] | Low platelet count results in mucosal bleeding therefore menorrhagia or previous episodes of post partum hemorrhage can occur [1] [2] [3] [4] [5] [6] [7] |
| Headache, confusion, sudden paralysis of a limb, aphasia [1] [2] [3] [4] [5] [6] [7] | Rarely <1% of patients, intra cranial bleeding may occur and these neurological symptoms can occur. [1] [2] [3] [4] [5] [6] [7] |
| In the neonate, spontaneous or prolonged bleeding after venipuncture or circumcision [9] | This raises suspicion of neonatal thrombocytopenia. The circulating antibodies can cross the placenta and platelet destruction in the baby and subsequent neonatal immune thrombocytopenia [9] |
| Fact | Explanation |
|---|---|
| Petechiae, Ecchymotic patches [4] [5] [6] [7] [8] | Petechiae are small (<3 mm) red or purple spot on the skin, caused by a minor hemorrhage and they do not blanch on pressure and Ecchymotic patches are larger than petechiae and these manifestations are due to low platelet count. [4] [5] [6] [7] [8] |
| Gum bleeding [1] [2] [4] [5] [6] [7] [8] | Low platelet count may result in bleeding from gums and can be clinically seen [1] [2] [4] [5] [6] [7] [8] |
| Hemorrhagic bullae in the oral cavity [1] [2] [4] [5] [6] [7] [8] | Oral lesions could be the initial manifestations and these include petechiae, purpura, ecchymosis, hemorrhagic bullae, and hematoma formation [1] [2] [4] [5] [6] [7] [8] |
| Retinal hemorrhages [3] | Low platelet count can also cause bleeding in the retina which can be detected by ophthalmoscope. [3] |
| Pallor [3] [4] [5] [6] [7] [8] | Sometimes bleeding may be profuse to cause anemia and clinical pallor [3] [4] [5] [6] [7] [8] |
| In the neonate hypotonia, reduced movements of limbs [9] | This raises the suspicion of cerebral hemorrhage due to neonatal thrombocytopenia due to placental crossing of maternal antibodies [9] |
| In the neonate prolonged bleeding from venepuncture sites, circumsicion site [9] | This raises the suspicion bleeding tendency due to neonatal thrombocytopenia due to placental crossing of maternal antibodies [9] |
| Fact | Explanation |
|---|---|
| Drug-induced thrombocytopenia [2] [3] | Drug-induced thrombocytopenia occurs when certain medicines cause destruction of platelets or impairment of production. Heparin, a is the most common cause of drug-induced immune thrombocytopenia. Certain drugs such as chemotherapeutics, antiepilepitcs may cause marrow suppression and non immune thrombocytopenia. Other medicines that cause drug-induced thrombocytopenia include Furosemide Gold, Nonsteroidal anti-inflammatory drugs (NSAIDs), Penicillin, Quinidine, Quinine, Ranitidine, Sulfonamides, Linezolid and other antibiotics [2] [3] |
| Viral infections [4] | Infections can cause thrombocytopenia by direct bone marrow suppression or increased peripheral platelet consumption. Common viruses include hepatitis B and C, human immunodeficiency virus, Epstein-Barr, cytomegalovirus, parvovirus B19, varicellazoster, rubella, and mumps. Recent studies found thrombocytopenia in 14 percent of hospitalized patients with influenza A (H1N1) virus [4] |
| HELLP syndrome [5] | Pregnant mothers with pregnancy induced hypertension when present with thrombocytopenia or signs and symptoms such as headache, visual disturbances, right upper quadrant abdominal pain, or elevated blood pressure should be evaluated for preeclampsia and HELLP syndrome. Laboratory investigations show anemia, elevated liver enzymes, elevated lactate dehydrogenase, and proteinuria [5] |
| Hemolytic-Uremic Syndrome [6] [7] | Hemolytic-uremic syndrome (HUS) is a triad of progressive renal failure, microangiopathic hemolytic anemia and thrombocytopenia. [6] [7] |
| Disseminated Intravascular Coagulation [8] | Disseminated intravascular coagulation (DIC) is systemic activation of clotting mechanisms and contributing to multiple organ dysfunction syndrome (MODS) by forming microvascular thrombi in various organs., In DIC patient will be very ill and consumption of platelets may cause a thrombocytopenia. [8] |
| Gestational thrombocytopenia [9] | Hemodilution and accelerated platelet clearance causes gestational thrombocytopenia and this doesn't affect the baby and recovers spontaneous after delivery.[9] |
| Systemic Lupus Erythematosus in pregnancy [10] [11] | Systemic lupus erythematosus (SLE) is an autoimmune disorder and can excerbate during pregnancy with arthritis, rashes, and fatigue. Rashes occur in SLE can mimic ITP. [10] [11] |
| Thrombotic Thrombocytopenic Purpura [12] | Thrombotic Thrombocytopenic Purpura (TTP) is rare and clotting results in a low platelet count. It has a pentad of clinical features including, fever, neurologic abnormalities, thrombocytopenic purpura, microangiopathic hemolytic anemia, and renal disease. [12] |
| Type II B von Willebrand disease (vWD) [13] | An inherited disorder with dysfunction or deficiency of the protein termed von Willebrand factor (vWF) and type II B is a qualitative deficiency of the factor and associated with low platelet count [13] |
| Acute fatty liver of pregnancy [1] | There's accumulation of fatty acids in hepatocytes due to mitochondrial oxidation defetc. Clinically they have non specific symptoms such as malaise, nausea and vomiting, right upper-quadrant and epigastric pain. [1] |
| Antiphospholipid Syndrome [14] [15] | Recurrent venous or arterial thrombosis and/or fetal loss are the principal manifestations in antiphospholipid syndrome and sometimes can mimic ITP because of thrombocytopenia. [14] [15] |
| Fact | Explanation |
|---|---|
| Full blood count [1] [2] [3] [4] [5] [6] | Platelet counts are low as well as hemoglobin could be low due to bleeding. White cell count is also important to exclude any infective cause [1] [2] [3] [4] [5] [6] |
| Peripheral smear [1] [2] [3] [4] [5] [6] | Platelets are normal to large in size. Red and white blood cells are usually normal in ITP [1] [2] [3] [4] [5] [6] |
| Antiplatelet antibodies [1] [2] [3] [4] [5] [6] | This test is not commonly done but these can be detected in the serum of women with ITP. [1] [2] [3] [4] [5] [6] |
| Bone marrow aspiration [1] [2] [3] [4] [5] [6] | This may demonstrate increased numbers of megakaryocytes. Usually this is not necessary unless patient is having lymph node enlargement or organomeagly. But this is usually done before splenectomy. [1] [2] [3] [4] [5] [6] |
| Prothrombin time/activated partial thromboplastin time [1] [2] [3] [4] [5] [6] | These tests are done to exclude any coagulation factor deficiencies [1] [2] [3] [4] [5] [6] |
| Hepatitis B and C and HIV serologies [1] [2] [3] [4] [5] [6] [7] | Hepatitis B, C and HIV need to be excluded, therefore these tests are done. [1] [2] [3] [4] [5] [6] [7] |
| Antinuclear antibody [1] [2] [3] [4] [5] [6] | To exclude SLE, this is done [1] [2] [3] [4] [5] [6] |
| Antiphospholipid antibodies [1] [2] [3] [4] [5] [6] | To exclude Antiphospholipid syndrome, this is done [1] [2] [3] [4] [5] [6] |
| A direct antiglobulin test or Coombs test [2] [3] [4] | This is necessary to rule out complicating autoimmune hemolysis (Evans syndrome) [2] [3] [4] |
| liver functiontests for bilirubin, albumin, total protein, transferases, and alkaline phosphatase [2] [3] [4] | To exclude liver disease causing thrombocytopenia [2] [3] [4] |
| Cord blood of the neonate for full blood count [8] | when neonatal thrombocytopenia is suspected, cord blood is checked for platelet count at birth [8] |
| Fact | Explanation |
|---|---|
| Full blood count [1] [2] | To assess the platelet count, hemoglobin count prior to surgery [1] [2] |
| Coagulation studies [1] [2] | To exclude any coagulopathy prior to surgery [1] [2] |
| Renal function tests- Serum Creatinine, Blood urea nitrogen [1] [2] | To exclude any renal dysfunction prior to anesthesia [1] [2] |
| Grouping and Rh [3] [4] [5] [6] | Prior to starting anti D immunoglobulin as a treatment in Rh positive mothers [3] [4] [5] [6] |
| Fact | Explanation |
|---|---|
| Full blood count [1] [2] [3] [4] [5] | To assess the platelet count [1] [2] [3] [4] [5] |
| Fasting blood sugar [6] | As the patients are started on steroid therapy, to detect development of diabetes [6] |
| Fact | Explanation |
|---|---|
| Viral screening ( HIV, hepatitis C virus, and hepatitis B virus) [1] [2] [3] | As these virus infections can also produce a similar clinical picture and can cause thrombocytopenia [1] [2] [3] |
| Thyroid function tests [4] | Anti thyroid antibodies are found to be prevalent in patients with ITP probably due to auto immune nature. Therefore this tests may be done but could be normal [4] |
| Fact | Explanation |
|---|---|
| Patient education [1] [2] [3] [4] [5] [6] | Patient should be educated regarding the nature, course and prognosis of the disease. Also should be reassured that there will be no harm for the baby due to the disease, and should be advised on the importance of follow up and available treatment options. Patient should be educated on warning signs such as headache, paralysis of a limb, aphasia (Features of intracranial hemorrhage)to seek immediate medical attention. [1] [2] [3] [4] [5] [6] |
| Follow up [1] [2] [3] [5] [6] | No treatment is necessary if platelet counts remain above 50,000/μL and the patient is asymptomatic. Therefore regular follow up of the patient is important with attending to obstetric care. [1] [2] [3] [5] [6] |
| Activity [1] [2] [3] [4] [5] [6] | When there is very low platelet count, any activity which can cause trauma is better avoided [1] [2] [3] [4] [5] [6] |
| Acute management of a life threatening hemorrhage [1] [2] [3] [5] [6] [7] | Patient should be resuscitated first with attending to airway, breathing and circulation. Platelet transfusion is carried out in this instance for a rapid response. [1] [2] [3] [5] [6] [7] |
| Fact | Explanation |
|---|---|
| Steroid therapy [4] [5] [6] [7] [10] | Prednisolone is used as the first line treatment. But treatment is not needed if platelet counts remain above 50,000/μL and the patient is asymptomatic. But even if the patient is having abnormal bleeding, or prior cesarean delivery which is invasive treatment will be carried out. [4] [5] [6] [7] [10] |
| Intravenous immune globulin (IVIG) [4] [5] [6] [7] [10] | IV immunoglobulin blocks the attachment of antiplatelet antibodies to platelets and gives a rapid response. especially in instances such as prior to surgery or bleeding. But this is very expensive. [4] [5] [6] [7] [10] |
| Anti-D immunoglobulin [4] [5] [6] [7] [10] | This is for Rh-positive women but still controversial when it comes to use. Anti-D immunoglobulin binds to maternal red blood cells and blocks the Fc receptor. Then there's phagocytosis of these anti D bound red blood cells in the reticulo-endothelial system in the spleen. [4] [5] [6] [7] [10] |
| Azathioprine [8] [10] | This is the only immunosuppressive drug used in pregnancy. Vinca alkaloids, androgens, and most immunosuppressive drugs are not recommended in pregnancy. Dapsone, and Danazol are not recommended in pregnancy. [8] [10] |
| Splenectomy [8] [10] | Antibody bound platelets are destructed in the spleen. Therefore aplenectomy will help to chieve remission and carried out in first and second trimesters. Prior to splenectomy, immunization against pneumococcus, meningococcus, and Haemophilus influenzae is done. [8] [10] |
| Management of the delivery [10] | Vaginal delivery is carried out unless a obstetric reason justifies the C-section. Platelet transfusions, IV Ig might be helpful in the management of delivery. [10] |
| Management of neonatal thrombocytopenia [1] [2] [3] [10] | cord blood platelet count determined at birth and again at 24 hours in these newborns born to mothers with ITP. And then repeated daily for the next few days. Any neonates with severe thrombocytopenia (platelets < 30 × 109/l) is treated with IVIG regardless of presence or absence of bleeding. [1] [2] [3] [10] |