What are the management recommendations for a 41-year-old female with chronic thrombocytopenia (platelet count) and type 2 diabetes (T2D), who is 14 weeks pregnant?

Management of Chronic Thrombocytopenia in Pregnancy with Type 2 Diabetes

For a 41-year-old female with chronic asymptomatic thrombocytopenia (platelet count 79×10^9/L) at 14 weeks of pregnancy and well-controlled type 2 diabetes, no immediate treatment is required, but close monitoring of platelet counts is recommended until OBGYN consultation can be arranged. 1

Assessment of Current Status

• Current platelet count: 79×10^9/L

  • This level is considered mild thrombocytopenia and is above the threshold requiring intervention during the first two trimesters
  • This level is sufficient for most procedures and is above the 75×10^9/L threshold recommended for epidural anesthesia 1

• Diabetes status: Well-controlled (A1c 5.9%) with diet management

  • Good glycemic control is important to minimize pregnancy complications

Management Recommendations

Immediate Management

1. No immediate treatment needed

   • According to international consensus guidelines, treatment during the first two trimesters is only initiated when:
     • The patient is symptomatic
     • Platelet counts fall below 20-30×10^9/L
     • An increase in platelet count is needed for procedures 1

2. Monitoring plan

   • Schedule regular platelet count monitoring (every 2-4 weeks initially)
   • Increase frequency of monitoring as delivery approaches 1
   • Continue monitoring blood glucose and A1c levels

Referrals

• Expedite OBGYN referral - preferably to a high-risk obstetrics specialist
• Hematology consultation - to confirm diagnosis and assist with management
• Anesthesiology consultation - to plan for potential delivery needs

Diagnostic Considerations

Confirm the diagnosis of ITP by ruling out other causes of thrombocytopenia in pregnancy:

• Gestational thrombocytopenia (typically occurs later in pregnancy)
• Preeclampsia/HELLP syndrome
• Antiphospholipid syndrome
• Other causes 1, 2

Recommended Tests

• Complete blood count with peripheral smear
• Liver function tests
• Renal function tests
• Coagulation studies
• Consider testing for antiphospholipid antibodies if history suggests

Planning for Later Pregnancy

Third Trimester Considerations

• Target platelet count for delivery:
  • ≥50×10^9/L for cesarean section
  • ≥75×10^9/L for epidural/spinal anesthesia 1

Treatment Options if Needed Later

If platelet counts drop significantly or intervention becomes necessary:

1. First-line treatments:

   • Corticosteroids: Prednisone 10-20 mg/day, adjusted to minimum effective dose

     • Note: May affect glycemic control in a patient with diabetes 1

   • IVIg: Consider if corticosteroids are ineffective or contraindicated

     • Well tolerated and can be repeated as needed 1

2. Mode of delivery:

   • Should be determined by obstetric indications rather than platelet count alone 1

Important Considerations and Pitfalls

• Diabetes management: Corticosteroid treatment, if needed later, can worsen glycemic control

  • More intensive glucose monitoring would be required if steroids are initiated

• Avoid these medications:

  • Vinca alkaloids, rituximab, danazol, TPO-receptor agonists, and most immunosuppressive drugs (except azathioprine) due to possible teratogenicity 1

• Neonatal considerations:

  • Risk of neonatal thrombocytopenia is low but present
  • Maternal platelet count does not reliably predict fetal platelet count 1

• Reassurance: Studies have shown that pregnancy in women with ITP can proceed safely with low hemorrhagic risk for both mothers and infants 1