A 32-year-old woman, gravida 1 para 0, comes to the office at 30 weeks gestation for thrombocytopenia evaluation. The patient was found to have a platelet count of 110,000/mm³ during routine blood tests performed at 28 weeks gestation. She reports no history of blood disorders and has had no easy bruising, epistaxis, gingival bleeding, or blood in the urine or stool. Her pregnancy has been uneventful, and her only medication is a prenatal vitamin. The patient drank alcohol occasionally but stopped after conceiving. She does not use tobacco or illicit drugs.
Vital signs are within normal limits. There is no scleral icterus or lymphadenopathy. Skin examination shows no petechiae or ecchymosis. The uterus is appropriate in size for gestational age. Bilateral lower extremity 1+ pitting edema is present.
Laboratory testing performed today reveals the following:
Peripheral smear shows no platelet clumping. Urinalysis reveals 1+ proteinuria. An anatomy ultrasound reveals normal fetal development, and the first trimester HIV screening was negative.
Which of the following is the most appropriate next step in management of this patient?

Question

A 32-year-old woman, gravida 1 para 0, comes to the office at 30 weeks gestation for thrombocytopenia evaluation. The patient was found to have a platelet count of 110,000/mm³ during routine blood tests performed at 28 weeks gestation. She reports no history of blood disorders and has had no easy bruising, epistaxis, gingival bleeding, or blood in the urine or stool. Her pregnancy has been uneventful, and her only medication is a prenatal vitamin. The patient drank alcohol occasionally but stopped after conceiving. She does not use tobacco or illicit drugs.
Vital signs are within normal limits. There is no scleral icterus or lymphadenopathy. Skin examination shows no petechiae or ecchymosis. The uterus is appropriate in size for gestational age. Bilateral lower extremity 1+ pitting edema is present.
Laboratory testing performed today reveals the following:

Peripheral smear shows no platelet clumping. Urinalysis reveals 1+ proteinuria. An anatomy ultrasound reveals normal fetal development, and the first trimester HIV screening was negative.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Gestational thrombocytopenia (GT) is a benign, self-limited condition that occurs in 5%-7% of pregnancies. Most cases are discovered late in gestation (usually at delivery), but GT can arise as early as the first trimester. GT is usually discovered incidentally as it is not associated with bruising, bleeding, physical examination abnormalities, or neonatal thrombocytopenia. Platelet counts are almost always 100,000-150,000/mm³; thrombocytopenia <80,000/mm³ should prompt an evaluation for an alternate diagnosis. Women with GT should continue normal prenatal care and delivery management; no further testing or treatment is required. Platelet counts usually normalize within 6 weeks of delivery. ³ The differential diagnosis of GT includes immune-mediated thrombocytopenia (ITP). However, because ITP is a diagnosis of exclusion, it is impossible to distinguish between GT and mild ITP (platelet count >100,000/mm³) in pregnancy; GT is much more likely because it is much more common. Antiplatelet antibody testing is not used for the diagnosis of ITP due to low sensitivity and specificity (Choice A). Patients with suspected ITP who have platelet counts <30,000/mm³ are usually treated with high-dose corticosteroids (plus platelet transfusion and intravenous immunoglobulin) (Choice D). Those who continue to have platelet counts <20,000/mm³ after this treatment often receive splenectomy, rituximab, or thrombopoietin-receptor agonists (Choice E). Mild ITP without bleeding generally does not require ITP-specific therapy. ³ ³ ³ (Choice B) Bone marrow disorders (eg, myelodysplasia) can cause thrombocytopenia but are usually associated with other cytopenias and morphologic abnormalities on peripheral blood smear. These conditions are far less common in pregnancy than GT. Educational objective: Gestational thrombocytopenia is the most common cause of thrombocytopenia in pregnancy and usually arises late in gestation (often at delivery). Platelet counts are typically 100,000-150,000/mm³, so patients do not have bruising, bleeding, or physical examination abnormalities. The condition is benign and self-limited and requires no additional testing/treatment. ³ __________

A 32-Year-Old Woman, Gravida 1 Para 0, Comes to the Office