202412152330
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Haemostatic disorders in pregnancy
Thrombocytopenia
Platelet counts above 50×10^9/L are targeted before delivery, as surgical bleeding is less likely to occur above this level.
This threshold assumes platelets to be functionally normal
| Disease | Incidence in pregnancy (%) | Platelets | Features | CNB | Other |
|---|---|---|---|---|---|
| GT | 5–9 | Typically >70×109 L−1 Majority above 100×109 L−1 If less than 70×109 L−1 should be investigated for other causes Normal platelet function |
Onset often in third trimester Spontaneously resolves Asymptomatic No neonatal effects |
Safe if platelets >75×109 L−1 and no other adverse features Can be considered at platelets >50×109 L−1 if stable/no adverse features |
May deliver in a midwife-led unit if platelets stable and above 100×109 L−1 |
| ITP | <1 | Typically <100×109 L−1 Platelets appear large on a blood film Platelets are hyper-functional |
Can be a preexisting disease Can be asymptomatic, minor bruising, petechiae or significant bleeds Onset any trimester Can cause neonatal thrombocytopenia |
As for GT | Deliver in an obstetric-led unit with a neonatal unit Avoid ventouse Use mid-cavity forceps with caution |
| Pre-eclampsia | 5–8 | Platelet count can decrease rapidly Reduction in platelet count may precede other symptoms |
Onset after 20 weeks' gestation SBP >140 mmHg or DBP >90 mmHg with proteinuria May have headache, visual disturbance, subcostal pain, and oedema |
Safe if platelets >100×109 L−1 Can be considered if platelets >75×109 L−1 and stable with normal clotting studies |
Deliver in an obstetric-led unit with a neonatal unit |
| HELLP | <1 | Platelet count can decrease rapidly Reduction in platelet count may precede other symptoms |
Raised LFTs and LDH Micro-angiopathic haemolytic anaemia Features of pre-eclampsia 15% have no hypertension or proteinuria |
Could be considered if platelets >75×109 L−1, and stable platelet count and clotting studies should be checked immediately before the procedure Treat as severe pre-eclampsia |
Deliver in an obstetric-led unit with a neonatal unit |
| AFLP | <0.01 | Typically >50×109 L−1 | Onset third trimester Abdominal pain and jaundice Hepatic encephalopathy Raised LFTs, ammonia, creatinine Deranged clotting studies Hypoglycaemia |
Case reports of use in a well patient with no bleeding history and normal clotting studies | Referral to an ICU or a specialist liver unit may be required |
Gestational thrombocytopenia
Gestational thrombocytopenia (GT) accounts for 75% of patients presenting with low platelets in pregnancy.
The majority have platelet counts above 100×10^9/L, but 10% are below this.
It usually presents in the third trimester, resolves spontaneously after delivery, causes no adverse fetal effects and patients are asymptomatic.
It tends to recur in subsequent pregnancies, but in between the platelet count remains normal
The pathophysiology remains unknown, but theories include insufficient thrombopoietin and increased consumption and turnover
| Platelet Count | Recommendation | 95% CI for risk of spinal epidural hematoma |
|---|---|---|
| 70–99 × 109/L | May be reasonable to proceed | 0–0.19% |
| 50–69 × 109/L | Individualized risk/benefit analysis | 0–2.6% |
| 0–49 × 109/L | May be reasonable to avoid | 0–9% |