What is the management approach for a 22-week pregnant patient with thrombocytopenia, normal platelet indices, and normal total leukocyte count (TLC), hemoglobin (Hb), and red blood cell (RBC) count, considering her limited financial resources?

Management of Thrombocytopenia in Pregnancy

For a 22-week pregnant patient with isolated thrombocytopenia (normal platelet indices, normal TLC, Hb, and RBC), treatment is generally not required unless the platelet count is below 20-30×10^9/L, the patient is symptomatic, or procedures are planned. 1

Diagnostic Approach for Limited Resources

Given financial constraints, focus on essential investigations:

1. Determine platelet count severity:

   • Mild (100-150×10^9/L)
   • Moderate (50-100×10^9/L)
   • Severe (<50×10^9/L)

2. Essential low-cost investigations:

   • Blood pressure measurement (to rule out preeclampsia) 2
   • Liver function tests (to exclude HELLP syndrome and other liver disorders) 2
   • HIV testing if risk factors present 2
   • Peripheral blood smear examination (to exclude other causes of thrombocytopenia) 2

3. Avoid unnecessary tests:

   • Bone marrow examination is not required for diagnosis of ITP in pregnancy 2
   • Maternal antiplatelet antibody testing has no value in routine diagnosis 2

Management Algorithm Based on Platelet Count

If platelet count >50×10^9/L:

• No treatment required
• Monitor platelet count every 2-4 weeks initially
• Increase monitoring frequency in third trimester 1

If platelet count 30-50×10^9/L:

• Generally no treatment required in second trimester
• Close monitoring every 2 weeks
• Prepare for possible treatment as delivery approaches 2

If platelet count 10-30×10^9/L:

• Treatment indicated if:
  • Patient has bleeding symptoms
  • In third trimester (not applicable for your 22-week patient yet)
  • Procedures are planned 2
• First-line treatment options:
  • Prednisone 10-20 mg/day (low-cost option) 2
  • Adjust to minimum effective dose that maintains safe platelet count

If platelet count <10×10^9/L:

• Treatment required regardless of symptoms 2
• Options:
  • Prednisone 10-20 mg/day (adjust to minimum effective dose) 2
  • IVIg if available (more expensive but effective) 2

Important Considerations

1. Medication precautions:

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

2. Monitoring plan:

   • Increase frequency of platelet count monitoring as delivery approaches
   • Monitor more closely in third trimester as platelet counts may fall 1

3. Delivery planning:

   • Target platelet count ≥50×10^9/L for cesarean section
   • Target platelet count ≥75×10^9/L for epidural/spinal anesthesia 1
   • Mode of delivery should be determined by obstetric indications rather than platelet count alone 2

4. Neonatal considerations:

   • Cord blood platelet count should be checked after delivery 2
   • Transcranial ultrasonography should be performed on neonates with platelet counts <50×10^9/L 2

Cost-Effective Management Tips

1. Use oral prednisone as first-line therapy (more affordable than IVIg) 2
2. Minimize frequency of platelet count monitoring while maintaining safety (every 2-4 weeks if stable)
3. Reserve more expensive treatments (IVIg) for cases not responding to corticosteroids or requiring rapid platelet increase 2
4. Collaborate with obstetrician to determine minimum testing needed for safe management

Remember that pregnancy in women with thrombocytopenia can generally proceed safely with low hemorrhagic risk for both mother and infant when properly managed 2, 1.