What are safe platelet levels and treatment in pregnancy?

Question

Hello doctor,

My 34-year-old sister has been dealing with chronic immune thrombocytopenia for 5 years now, and it is getting worse. Her platelet count stays between 8,000 and 15,000 most of the time, when normal is 150,000 to 400,000.

She has had multiple bleeds, including nosebleeds that will not stop, bruises all over from just touching things, and heavy menstrual bleeding that lasts 10 to 12 days. Last month, she had to get a platelet transfusion before dental cleaning because the count was only 6,000.

She tried Prednisone, which worked temporarily, but she cannot stay on it long term because of weight gain and mood changes. She also tried Rituximab infusions, but they only worked for a few months.

Her haematologist tried intravenous immunoglobulin treatments monthly. The chronic immune thrombocytopenia is affecting her fertility, too. She has had two miscarriages because the platelet count drops even lower during pregnancy. Now she is scared to try again, but really wants a baby.

They are talking about removing her spleen, but the success rate is only 60 to 70 percent. What are newer treatments for chronic immune thrombocytopenia? Can she safely have a baby with platelets this low?

Kindly help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I read your query and understood your concern.

Let me explain to you. Immune thrombocytopenia (ITP) occurs when your immune system destroys your own platelets. Many women with chronic immune thrombocytopenia can have successful pregnancies, but it does require close coordination between your haematologist and obstetrician (preferably a high-risk or maternal-fetal medicine specialist).

Risks of pregnancy with ITP.

Bleeding risk: With platelets around more than 30,000 per microlitre to 50,000 per microlitre, most women are safe from spontaneous bleeding, although bruising and gum bleeding may occur. The main risk is excessive bleeding during delivery or postpartum, particularly if platelets fall below 50,000 per microlitre. Epidural anaesthesia is generally avoided if platelets are less than 80,000 per microlitre due to spinal bleeding risk.
Miscarriage: Chronic immune thrombocytopenia itself does not cause miscarriage. However, some autoimmune or secondary causes, such as lupus-associated thrombocytopenia, can cause miscarriage, and your doctor may screen for these.
For the baby: Maternal antibodies can cross the placenta and cause neonatal thrombocytopenia in about 10 percent to 15 percent of babies, but severe bleeding in the newborn is rare (less than one percent).

Safe platelet levels during pregnancy vary depending on the stage and the procedure planned. Throughout pregnancy, a platelet count greater than or equal to 30,000 per microlitre is generally considered sufficient to prevent spontaneous bleeding.

At delivery, a platelet count greater than or equal to 50,000 per microlitre is recommended to ensure safety for vaginal or caesarean delivery. If an epidural is planned, the platelet count should be greater than or equal to 80,000 per microlitre to avoid the risk of spinal haematoma.

For management, it is recommended to take a tablet of Folic Acid, 5 milligrams, during the first trimester and continue vitamin D3 supplementation until the end of pregnancy.

I suggest you consider the following:

You should involve a multidisciplinary team.
You should consult a hematologist.
You should consult a specialist in blood banking.
You should consult a gynecologist.
Start tablet Prednisolone 20 mg, increasing up to 60 mg.
Give intravenous immunoglobulin (IVIG).
Consider splenectomy.

I hope that this answers your query.

Kindly follow up if you have more doubts.

Thank you.