Thrombocytopaenia of Pregnancy – Low Platelets

I experience thrombocytopaenia of pregnancy, which affects about 5-7% of women. It has no other symptoms apart from low platelet levels. Platelet counts are lower than normal by the end of pregnancy and return to normal levels soon after birth. No-one knows why it happens and it is not passed to the baby. It is usually quite mild (platelets remain above a count of 50 and prevent no real threat to mother either).

The problem with low platelets is that it is impossible to diagnose the difference between thrombocytopaenia of pregnancy and a more serious low platelet condition called ITP which is sometimes diagnosed for the first time during pregnancy. It can also be part of pre-eclampsia or HELLP syndrowm which are serious – but which of course have other syptoms. Low platelets alone, as long as they are not really really low (below 20) seem to present no cause for concern to the experts, but can worry some health professionals!

My low platelet count was first discovered during a routine full blood count during my first pregnancy. I was referred to a haematologist at the hospital who said she would not worry as long as my platelet count remained above 80 which it did (just).

Towards the end of that pregnancy an obstetrician tried to panic my midwives, saying I would bleed to death and that it was crazy to contemplate a home birth in these circumstances. At that point my GP intervened and spoke to Wendy Savage (who was then head obstetrician at our local hospital) who went back to research evidence and said there was no greater risk associated with homebirth connected to my platelet count. The home birth went ahead, no probs, and nothing more was said.

I had the same condition again in my second pregnancy but no-one took a blind bit of notice as I presented myself as someone who experiences gestational thrombocytopaenia. Again, another straightforward home birth.

Third (current) pregnancy, it’s happening again. I had platelets at the very bottom end of “normal” ie. 150 at my booking appointment, and expect they will continue to fall during the pregnancy. I intend to have another home birth and don’t expect this to cause any problems.

Claire Davis

My local hospital runs a complete blood count which includes platelet levels.

Friend ‘A’, a Primigravida booked for a home birth with the community team, is told she has a lowered platelet count and when she asks to see a hematologist he says there should not be a worry until platelets fall below 100. Hers do not fall below 113 and home birth went ahead two months ago.

Friend ‘B’ a secundigravida with no history of ITP in first birth has same thing happen except her platelets feel to 98 this week. Consultant OB said home birth out and they have just done another test which I hope is to establish IgG etc. They have told her there could be bleeding risks for her and also for baby and they want her in hospital to test baby immediately after birth.

I have been asked to be a helper in a non-midwife capacity at this birth, and although I have no issue with giving them all the information I have and in telling them that once they have the information they need to sit down and look within to see if they both feel safe and trusting that all is OK or whether they feel a twinge of doubt. That twinge of doubt in and of itself will probably cause a problem of somekind along the way (in my opinion).

However, I have not managed to get enough information to satisfy my own questions.

1) If I were worried about bleeding would I not be looking at HELLP issues and checking liver?

2) I am having trouble extrapolating the percentages of diagnosed low platelets into true ITP and the benign gestational variety as the percentage of women given in what I have researched includes those first time mothers with whom it is only in retrospect you can diagnose and my friend is a second timer. What do you all think is the real likelihood of it being the real thing?

3)If the mum is unaffected but there could be problems with the baby, why can’t the cord blood be taken straight to local hospital (8 miles) and tested after a home birth ..ie is the sample inherently unstable?

4) If the sample is positive and baby had < 50 count, what again are the chances of something happening between birth, sample being taken and worked on and the extra time it takes to get babe to hospital? Assuming that there is not obvious trauma to baby with birth, which again is unlikely in a natural second time home birth. Of course they would transport if there were signs of bruising, just in case baby is positive? 5) any stories or experiences appreciated. Tania

Incidental Thrombocytopaenia of Pregnancy, by Claire Davis

I have had incidental thrombocytopaenia of pregnancy in all of my 3 pregnancies and have educated myself as best I can about low platelets conditions.

The level of 98 platelets for friend B does not sound as if it presents a bleeding risk. I have 86 platelets and am in early labour and everyone is happy here! My hematologist was comfortable with home birth as long as platelet count remained above 80, and I would have argued for 70 as, from the articles about low platelets I have read, a count of 70 is still counted as mild thrombocytopaenia (and presents no bleeding risk for the mother).

It is impossible to say whether friend B’s low platelets are to do with this kind of mild thrombocytopaenia, or a more serious low platelet condition, and proper diagnosis will only be possible after the birth when we see whether her platelet count returns to normal and whether the baby has low platelets. In the more serious conditions, a more serious drop in platelet count would be expected, from earlier in the pregnancy, but this does not happen in all cases.

In my first pregnancy I had no past history of low platelets but delivered at home with a platelet count between 80-90. Cord blood was taken from the baby at birth and that was that. Fortunately all was well. When Flora’s cord blood was taken to be tested it was done with no urgency whatsoever. I don’t think anyone really believed with platelets of 80-90 and no other symptoms that I was suffering from a scarey condition.

Wendy Savage ( who was the senior obstetrician involved in my care at that time) checked her research and concluded that home birth with platelets at that level was no more dangerous than any other birth.

Claire Davis
Clairedavis45@aol.com

Claire wrote “I have a platelet count of 86 and am in early labour and everyone is happy here!” .

She went on to give birth to Maud at home, after a gentle 13-hour labour. Maud weighed 10lb 2oz (4.6Kg), and Claire said “I didn’t need any stitches, had no vaginal exams, had lovely midwives around for most of the day, and the other girls met their sister within a few minutes of her birth.”

Claire had no syntometrine, and no abnormal blood loss.

LETTER TO GP

Dear Dr B…

Thanks for your note about my platelets. I just wanted to let you know that I don’t intend to have any further blood tests to monitor my platelet levels unless the hematologist has very good reasons why we should continue to “keep a close eye” on them until the baby is born.

As you know, I have had mild thrombocytopenia during both of my previous pregnancies. There have been no problems associated with this phenomenon – either for me or for my daughters. I have had completely natural births with physiological third stages of labour both times and have had no abnormal blood loss. Neither daughter has had a low platelet count. I have had no other “complications” during my pregnancies, and my platelet count has returned to a normal level soon after each birth.

All this leads me to conclude that I am one of the 7% (approx) of women who experience “incidental thrombocytopenia of pregnancy” rather than any of the more serious conditions which may be associated with low platelets – ITP, HELLP syndrome, pre-eclampsia etc. I have read as widely as I can about these conditions, and everything I have read indicates that incidental thrombocytopenia of pregnancy presents no risks for mother or fetus/infant and may well be simply a physiological variant of pregnancy rather than a disease. Incidental thrombocytopenia of pregnancy is always mild (with levels remaining above 70,000/µL in 100% of cases recorded in trials), so I do not see any reason for “keeping a close eye” on my platelets.

Of course, it is impossible to rule out with 100% certainty the possibility that my relatively low platelet count now is an indicator of one of the more serious conditions, and not simply a recurrence of the previous incidental thrombocytopenia of pregnancy. However, this would strike me as being very, very unlikely. I do not want to “manage” the final weeks of my pregnancy on the basis of a very unlikely worst-case scenario.

I recognize that I am not a hematologist, and that I only have access to publicly-available information about thrombocytopenia during pregnancy. I would be interested to hear what the hematologist´s reasons are for suggesting close monitoring of my platelet levels – perhaps there is more up-to-date research which contradicts what I have read?. My feeling at this stage is that the hematologist is being over-cautious, and recommending a level of surveillance which is not appropriate to me.

I intend to spend these last few days or weeks of my pregnancy relaxing, enjoying myself and preparing for another straightforward birth, and not worrying about potential problems which I do not believe exist. Please feel free to give me a ring on ….. with details of the hematologist´s concerns. Otherwise, I look forward to seeing you on 4 September for a routine antenatal appointment.

Thanks

Claire Davis

I had a low platelet count in my first pregnancy, (booked for a home birth with the community midwife), following a routine blood test at 34 weeks. My count was 79 and my midwife, who didn’t seem confident in delivering me at home anyway, tried to put the frighteners on re: bleeding to death in the event of a PPH, and attempted to persuade me into hospital.

This late in the pregnancy I was very determined not to go into hospital unless absolutely necessary and got in touch with AIMS and a couple of independent midwives. As a result I booked at 37 weeks with one of the independent midwives, who was wonderful and did a lot of work in the little time remaining to find out what the situation was regarding platelets. One of the people she got in touch with was a nutritionist and on her advice I started to take two supplements: Sea Plasma and Beetroot Extract. I also agreed to have weekly blood tests to monitor the situation.

My midwife wrote to a consultant haematologist at the hospital for advice. It was thought that the diagnosis was Chronic Idiopathic or Immune Thrombocytopenia, but this could not be confirmed without further tests.

The cut off point which they would have used for intervention for the management of labour was 70. In this event they would “prefer to give the patient a therapeutic trial of intravenous immunoglobulins prior to the onset of labour to be sure that she responds to these, and that she does not require an actual infusion of platelets. The plan then would be to give her therapeutic intravenous immunoglobulin or platelets, as appropriate, and to induce her. Unfortunately we cannot afford to leave her to go naturally into labour, as the response can be very short lived to the treatment………below 70 the effect of the fall in the platelet count becomes more pronounced, and I would anticipate she would be at risk of losing a large volume of blood with a PPH if her platelet count were less than 50………To conclude, I don’t believe this lady is suitable for a home confinement at all, and she should be under the active care of a Consultant Obststrician. The birth should be supervised in collaboration with the Haematology Department to ensure she has a safe delivery.”

My platelet count stabilised at 79 once I started taking the supplements and my midwife was happy to deliver me at home, I can’t remember what precautions specific to my platelet count were put in place at home, I know we had syntometrine in the fridge.

I didn’t have any of the testing or interventions suggested by this haematologist and did go into labour naturally. My son was born at home after a 21 hour labour weighing 8lbs 8oz. I had some bleeding from a tear as he came out with his hand against his face. I therefore agreed to have the syntometrine so that the midwives could find out quickly where the bleeding was coming from. Everything was fine, estimated blood loss was 400ml.

So much for needing blood products, an induction and two lots of consultants “to ensure a safe delivery” !!

Incidentally I have just had my second baby at home with the same midwife and my platelet count stayed higher this time (I took the same supplements from earlier in the pregnancy), only dropping from 164 at 9 weeks to 144 at 32 weeks.

Ruth

Links to other sources of information:

Thrombocytopenia During Pregnancy, by Abdul Rahim Gari-Bai, Fachartz (Hematology) 
(www.kfshrc.edu.sa/annals/182/97-160.html)

Thrombocytopenia in Pregnancy, by James N. George, MD
(http://moon.ouhsc.edu/jgeorge/Tpreg.html)

AH updated 20 May 2002