Second ITP pregnancy: overly cautious obstetrician

Hello,

I was diagnosed with ITP about 4 years ago. I had my first baby in 2014, he is now 18 months old. My usual non-pregnant platelet count fluctuates between the 60s and 80s and I have no symptoms and am not having any treatment. when I was pregnant last time my count dropped to around 40 very gradually over the course of the pregnancy. From the onset the obstetrician/haematology team were insisting on me considering a c-section or early induction despite my wishes to have a natural birth or at least attempt this. They decided they wanted my platelets to be 100 at delivery and sort around 30 weeks tried prednisolone which made me feel horrible and ill but helped with the platelet count. I didn't want to take it as I felt so awful and also because I felt there may be a risk to the baby in the long term (any info here would be great), so they did a 4-day course of Ivig. I responded to this but my platelet count didn't increase to their desired 100 and so they discontinued and planned to induce me at 37 weeks (or gave me the choice of a c-section at 37 weeks which I refused). Their rationale being that my count was near to 50 and if it got any lower they wouldn't want to give me an epidural (I didn't want one anyway) or be able to give me a spinal block for a c-section (they were adamant that it would end this way. After a horrible induction experience where I was left nil by mouth for 24 hours whilst in labour, I eventually had a emergency c-section. There were other issues with the birth that I wasn't happy with and the whole experience resulted in me having bonding issues with my little boy which took months to recover from.

My son is now 18 months and is well in every way, I breastfed him until about 17 months and I am now pregnant with baby no 2.

I am just 13 weeks pregnant with a platelet count of 83 and already the Obvs/haem team are telling me I will be induced at 37 weeks because of potential bleeding risks to the baby. I feel that they are being overly cautious reading all the research I can find and reading into other people's stories my platelets don't even seem that low compared to others. I'm also unsure of why they think s c-section is a safer option to a natural full term birth when surely there is more of a bleeding risk.

I'm wondering if anyone knows of any recent research in the subject which may help me discuss this with the doctors with more backing.

Thank you for any help,
Hannah x

This is the latest protocol that I am aware of, I hope it helps.

Throughout the first 2 trimesters, treatment is initiated (1) when the patient is symptomatic, (2) when platelet counts fall below 20 to 30 × 109/L, or (3) to produce an increase in platelet count to a level considered safe for procedures. Patients with platelet counts at 20 to 30 × 109/L or higher do not routinely require treatment. They should be monitored more closely as delivery approaches.

The lowest platelet count at which it is safe to administer spinal or epidural anesthesia remains controversial due to the theoretical risk of epidural hematoma formation and neurological damage. Obstetric anesthetists generally recommend a platelet count of at least 75 × 109/L to allow administration of spinal or epidural anesthesia. Hematologists believe that a platelet count of at least 50 × 109/L is adequate to allow for cesarean section.

Historically, management of delivery in mothers with ITP has been dominated by concerns over the risk of severe neonatal thrombocytopenia and hemorrhage (supplemental Document 8, Recommendation Box 10). In 1976, cesarean section was recommended for all ITP patients based on a reported perinatal mortality of 12% to 21%, largely resulting from birth trauma and ICH. However, these historical data were selective and excessively pessimistic. More recent reviews suggest the neonatal mortality rate of babies born to mothers with ITP is less than 1%. Large prospective studies published in the 1990s documented an incidence of “severe” neonatal thrombocytopenia (< 50 × 109/L) of 8.9% to 14.7%, with ICH occurring in 0% to 1.5% of infants with neonatal thrombocytopenia. There is no evidence that cesarean section is safer for the fetus with thrombocytopenia than uncomplicated vaginal delivery (which is usually safer for the mother). Moreover, most hemorrhagic events in neonates occur 24 to 48 hours after delivery at the nadir of the platelet count. Given the difficulty predicting severe thrombocytopenia in neonates and very low risk of serious hemorrhage (evidence level III, grade B recommendation), the mode of delivery in ITP patients should be determined by purely obstetric indications.

The decision about regional anesthesia is ideally made before delivery in conjunction with the obstetric anesthetist (supplemental Document 8, Recommendation Box 11). The general trend in recent years has been to lower the “cutoff point” to 75 to 100 × 109/L. However, there are no data to support a minimum required platelet count and each case must be individually considered, with the risk of the procedure (spinal hematoma) balanced against benefits (pain relief, better blood pressure control, avoidance of general anesthesia). There are too few reports of epidural hematoma following regional blockade in obstetric patients to give an incidence of this complication.

In the absence of bruising, bleeding history, and anticoagulation, and if the international normalized ratio (INR), activated partial thromboplastin time (APTT) test, and fibrinogen levels are normal, a small consensus of obstetric anesthetists agree no changes to routine practice are required until the platelet count drops below 50 × 109/L. For lower counts, a careful analysis of benefit against risk of epidural hematoma is needed, and multidisciplinary is discussion encouraged. Risk of vascular damage likely decreases proportionately to needle size, and consequently spinal may be a safer option than epidural blockade. An experienced operator is required (evidence level IV).

When monitoring platelet levels, the trend, as well as the absolute value, is important, and the mother with a rapidly falling count should be observed more closely than one with low but stable levels.

www.bloodjournal.org/content/115/2/168.full?sso-checked=true#sec-68

THANK YOU! That article is incredibly helpful and gives me all the information I need to speak with my doctors. I really appreciate the time you took.

Thank you x

You're welcome! I hope it helps. Let me know!