A 30 year-old-woman, gravida 1 para 0, at 29 weeks gestation comes to the office for a routine prenatal visit. She reports increasing fatigue, shortness of breath with exertion, and bilateral leg swelling over the past few weeks. The patient has had no vaginal bleeding, contractions, or leakage of fluid. Fetal movement is normal. Her initial prenatal visit was at 10 weeks gestation, and results of a complete blood count at that time were as follows: Today, blood pressure is 124/84 mm Hg, pulse is 77/min, and respirations are 22/min. Cardiac examination is normal, and the lungs are clear to auscultation bilaterally. Fundal height is 29 cm and fetal heart rate is 160/min. Bilateral lower extremities have 2+ pitting edema up to the knees. Results of a complete blood count today are as follows: Third-trimester HIV and syphilis tests are negative. Which of the following is the most appropriate management of this patient?

Question

A 30 year-old-woman, gravida 1 para 0, at 29 weeks gestation comes to the office for a routine prenatal visit.  She reports increasing fatigue, shortness of breath with exertion, and bilateral leg swelling over the past few weeks.  The patient has had no vaginal bleeding, contractions, or leakage of fluid.  Fetal movement is normal.  Her initial prenatal visit was at 10 weeks gestation, and results of a complete blood count at that time were as follows:  Today, blood pressure is 124/84 mm Hg, pulse is 77/min, and respirations are 22/min.  Cardiac examination is normal, and the lungs are clear to auscultation bilaterally.  Fundal height is 29 cm and fetal heart rate is 160/min.  Bilateral lower extremities have 2+ pitting edema up to the knees.  Results of a complete blood count today are as follows:  Third-trimester HIV and syphilis tests are negative.  Which of the following is the most appropriate management of this patient?

Quizplus · Accepted Answer

11ec25c8_da8b_9412_bc81_fd574fa8ad5e_MD0003_00 This patient most likely has gestational thrombocytopenia, a benign condition that causes an isolated, mild thrombocytopenia (ie, platelets 100,000-150,000/mm³). Gestational thrombocytopenia occurs in 5%-10% of pregnancies and is likely due to physiologic increases in plasma volume during pregnancy (ie, dilutional effect). It is commonly diagnosed in the third trimester on a routine complete blood count, as in this patient, but can arise as early as the first trimester. Patients are asymptomatic (ie, no bruising, bleeding, or anemia) or have normal physiologic symptoms of pregnancy, such as this patient's fatigue, shortness of breath, and symmetric leg swelling. Patients with isolated, asymptomatic, and mild thrombocytopenia in pregnancy are assumed to have gestational thrombocytopenia. Because this condition does not affect obstetric or neonatal outcomes and because platelet counts usually normalize within 6 weeks of delivery (ie, self-limited), management includes reassurance and observation. In contrast, symptomatic or moderate to severe thrombocytopenia (ie, <100,000/mm³) requires evaluation for an alternate diagnosis (eg, thrombotic thrombocytopenic purpura). (Choice A) A 24-hour urine collection for total protein is used to evaluate for preeclampsia, which can cause thrombocytopenia (ie, preeclampsia with severe features). However, these patients typically have platelet counts <100,000/mm³ and hypertension (ie, systolic ≥140 mm Hg or diastolic ≥90 mm Hg), which are not seen in this patient. (Choice B) Antinuclear antibody titers are elevated in autoimmune disorders (eg, systemic lupus erythematosus), which can be associated with immune-mediated thrombocytopenia (ITP). However, ITP typically causes platelet counts <100,000/mm³, making this diagnosis less likely. (Choice C) Coagulation studies can be used to evaluate patients with thrombocytopenia with abnormal bleeding or clotting (eg, disseminated intravascular coagulopathy), which is not seen in this patient. (Choice E) Von Willebrand factor activity levels are used to assess for von Willebrand disease, which causes impaired platelet-endothelial binding and reduced factor VIII levels. However, patients typically have abnormal bleeding and normal platelet levels, making this diagnosis unlikely in this patient. Educational objective: Patients with gestational thrombocytopenia are asymptomatic (ie, no bruising, bleeding, or anemia) and typically have mildly reduced platelet counts of 100,000-150,000/mm³. Gestational thrombocytopenia is benign and self-limited and is managed with reassurance and observation. References: Platelet counts during pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/29972751) Thrombocytopenic syndromes in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/27512485)

A 30 Year-Old-Woman, Gravida 1 Para 0, at 29 Weeks