Latest Treatment of Thrombocytopenia
Gestational thrombocytopenia is also known as incidental thrombocytopenia of pregnancy4. It is exclusive to pregnancy and presents in the late second or third trimesters. The decreased platelet count is associated with haemodilution, and with increased platelet 'trapping,' and with destruction in the placenta1. Usually asymptomatic, diagnosis often arises from a routine antenatal FBC5 or can be retrospective, after delivery4. The platelet levels gradually fall reaching 50-150 x 109 l by term. It is considered a benign condition6 and does not affect the fetus1. The platelet count usually returns to normal by six weeks postpartum4.
The complications of pre-eclampsia are numerous and include placental abruption, intrauterine growth restriction, HELLP syndrome (Haemolysis, Elevated Liver enzymes, Low Platelet count), disseminated intravascular coagulation (DIC), renal failure, pre-term delivery, multi-organ failure, eclampsia (grand mal seizures in the presence of pre-eclampsia) and even death.
This infant has the thrombocytopenia-absent radius (TAR) syndrome. There is absence of the radius bilaterally. Note diat the absence of the radius of the right forearm has resulted in a club hand. In the TAR syndrome the thumb is always present. Figure 1.40. This infant has the thrombocytopenia-absent radius (TAR) syndrome. There is absence of the radius bilaterally. Note diat the absence of the radius of the right forearm has resulted in a club hand. In the TAR syndrome the thumb is always present. Figure 1.42. This infant has Fanconi's syndrome. Note the congenital absence of the right radius and right thumb. In Fanconi's syndrome the thumb may occasionally be present. Note the club hand with absence of the radius and the diumb. This may be unilateral or bilateral. In Fanconi's syndrome there is pancytopenia (anemia, neutropenia, and thrombocytopenia) in addition to the hypoplastic or absent thumbs and hypoplastic or absent radius. Figure 1.44. Another example of...
Parenteral hydralazine was the most widely used drug in the acute treatment of hypertensive emergencies during pregnancy in the past. A maternal symptom-complex including headache, flushing, palpitations, nausea, and vomiting may develop, mimicking imminent eclampsia. There is limited experience with prolonged use of hydralazine in pregnancy. Symptomatic neonatal thrombocytopenia, leukopenia, petechial bleeding, and hematomas have been reported after prenatal exposure (Widerlov 1980). Therefore, chronic use should be reserved for refractory patients.
Hydrochlorothiazide, chlorthalidone, mefruside, bemetizide, ben-droflumethiazide, butizide, chlorazanil, clopamide, indapamide, metolazone, polythiazide, quinethazone, trichlormethiazide, and xipamide are bcnzthiazide derivatives whose action depends on the Inhibition of absorption of sodium and chloride in the distal tubule area. These drugs cause a potassium loss and lead to a reduction in the plasma volume In addition, they inhibit the excretion of uric acid. Benzthiazides are well-absorbed in the intestinal tract and are excreted unchanged in the urine. They cross the placenta and, when they are given sub partu, can lead to electrolyte changes (hyponatremia, hypokalemia), to thrombopenia, and to reactive hypoglycemia in the newborn as a result of their diabetogenic effect on the mother. In addition, prolonged labor has been described as a result of the inhibitory action on the smooth muscles.
These compounds are used in cases of heparin intolerability, such as heparin-induced thrombocytopenia (HIT). In a recent review, use in pregnancy was evaluated no indications of increased risk of adverse fetal outcome were observed (Lindhoff-Last 2005). Recommendation. In cases of heparin-induced thrombocytopenia (HIT), danaparoid may be prescribed. When one of the other abovementioned antithrombotics has been used during the first trimester, the termination of pregnancy or invasive diagnostics are not required.
Childbirth is the cure for preeclampsia as the disease process usually resolves within days of delivery. Delivery is always preferable from the perspective of maternal health. However, decisions on induction of labor or cesarean delivery must include a consideration of prematurity-related neonatal risks and the severity of the preeclampsia. Women with mild preeclampsia should be carefully followed until they are close to term and delivered at 37-39 weeks 30 . Women with severe preeclampsia may be expectantly managed until 32-34 weeks, or delivered sooner based on maternal and fetal status 31 . Women with preeclampsia need to have regular surveillance of the fetus with nonstress testing and amniotic fluid volume assessment. Blood work should be checked periodically to detect renal or hepatic involvement, hemolysis, or thrombocytopenia.
The symptoms previously mentioned in association with gall bladder disease in a non-pregnant state are mirrored in a pregnancy state. However, acute epigastric pain in pregnancy is a common symptom which can delay diagnosis and management of the condition. Other differential diagnoses include dyspepsia, pre-eclampsia, HELLP syndrome (haemolysis, elevated liver function, low platelets) and fatty liver disease.
Congenital malaria may occur in up to 10 of infants born to mothers not living in endemic areas (14). In most cases, clinical malaria manifests 3-8 weeks after birth, probably as a result of exchange of infected maternal erythrocytes at birth, and is characterized by fever, hepatosplenomegaly, jaundice, and thrombocytopenia (14). In areas of hyperendemicity, transplacental passage of maternal IgG may protect the newborn against development of clinical malaria (14).
Diagnosis is difficult as it is based on excluding other illnesses, such as SLE or von Willebrand's disease5, and side effects of drugs that cause a low platelet count. Additionally, 30 of patients do not have antibodies detected on laboratory investigation. If thrombocytopenia presents for the first time in pregnancy, diagnosis is complex, as pregnancy symptoms 'over-lap'1, and it is difficult to differentiate between gestational and immune thrombocytopenia. For this reason gestational thrombocytopenia may be considered a high-risk condition as well as ITP. The small IgG antibodies cross the placental barrier sometimes initiating neonatal thrombocytopenia4. Splenomegaly is rare in isolated thrombocytopenia7
There are no data on the other hirudin derivative, desirudin. These medications are used when heparin is not tolerated - for example, in cases of heparin-induced thrombocytopenia (HIT). Theoretically, no problems for the breastfed infant should be expected.
14.5 Thrombocytopenia in Pregnancy 1. Kam PC, Thompson SA and Liew AC 2004 Thrombocytopenia in the parturient. Anaesthesia, 59(3) 255-264 10. Fisher M, Peters B, McBride M and Kitchen V 1994 Consider HIV infection in thrombocytopenia. British Medical Journal, 308(6921) 133-136 12. Parnas M, Sheiner E, Shoham-Vardi I, Burstein E, Yermiahu T, Levi I, Holcberg G and Yerushalmi R 2006 Moderate to severe thrombocytopenia during pregnancy. European Journal of Obstetrics and Gynaecology, 127(1-2) 163-168
Low molecular-weight heparins (LMWHs) are increasingly preferred to unfractioned heparin (UH) for thromboprophylaxis, as well as for the treatment of VTE, and in the pregnant patient. They arc heparin fragments produced by chemical or enzymatic depolymeriza-tion, and their molecular weight ranges from 4000-6000 daltons. They specifically inhibit factor Xa. Their advantage lies in a longer half-life (injecting once a day), their better bioavailability (85 ), and their association with a lower incidcncc of osteoporosis, allergy, and heparin-induced thrombocytopenia (HIT), which may cause thrombotic events. There is evidence that LMWH. just like UH, do not cross the placenta.
In obstetrics, platelet transfusion is most likely to be seen either in the acute situation of haemorrhage, disseminated intravascular coagulopathy (DIC) or in a woman with ITP and evidence of impaired haemostasis. Also given prophylac-tically in a woman with a platelet count of less than 10,000 at risk of bleeding.
This may be given to women with a falling platelet count in immune thrombocytopenic purpura (ITP), prevention of fetal bleeding in feto-maternal alloimmune thrombocytopenia (FMAIT) and other immunologically based disorders. The dose is weight- and condition-based and is usually given once per week or two weeks. Infusion takes several hours.
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