What information should I establish in SOAP (Subjective, Objective, Assessment, Plan) format when referring an obstetric (OB) patient with thrombocytopenia to Internal Medicine Hematology (IM HEMA)?

SOAP Format for Referring OB Patient with Thrombocytopenia to IM Hematology

When referring an obstetric patient with thrombocytopenia to Internal Medicine Hematology, a comprehensive SOAP note with specific information is essential for optimal patient care and management. The following format provides the critical elements needed for an effective referral:

Subjective (S)

• Document any bleeding symptoms (type, severity, duration) including bruising, petechiae, gingival bleeding, epistaxis, or menorrhagia 1
• Record hemostasis history with prior surgeries or previous pregnancies 1
• Note any systemic symptoms that might suggest underlying disorders (fever, weight loss, arthralgias, skin rash) 1
• Document medication history, especially drugs associated with thrombocytopenia (heparin, quinidine/quinine, sulfonamides, alcohol) 1
• Include family history of thrombocytopenia or bleeding disorders 1
• Document lifestyle factors that might increase bleeding risk (physical activities, occupation) 1
• Note current gestational age and details of current pregnancy course 2

Objective (O)

• Record complete blood count trends, focusing on platelet count values and trends over time 1
• Document physical examination findings, particularly:
  • Bleeding signs (petechiae, purpura, ecchymosis) 1
  • Presence/absence of splenomegaly or hepatomegaly (splenomegaly suggests against ITP) 1
  • Lymphadenopathy 1
  • Signs of autoimmune disorders 1
• Include results of already completed laboratory tests:
  • Complete blood count with peripheral smear review 1
  • Coagulation studies (PT, INR, aPTT, fibrinogen) 1
  • Liver function tests 1
  • Tests to rule out secondary causes of thrombocytopenia if already performed (HIV, HCV, H. pylori) 1

Assessment (A)

• Provide your preliminary assessment of thrombocytopenia etiology, differentiating between:
  • Gestational thrombocytopenia (most common, typically platelet count >70,000/μL) 2
  • Immune thrombocytopenia (ITP) 2
  • Preeclampsia/HELLP syndrome 2
  • Secondary thrombocytopenia (drug-induced, infection-related) 1
• Document severity of thrombocytopenia and associated bleeding risk 1
• Note current gestational age and estimated delivery date 2
• Include assessment of potential risks for both mother and fetus 2

Plan (P)

• Specify reason for hematology referral and urgency 2
• Document any immediate management already initiated 2
• Include considerations for:
  • Monitoring frequency of platelet counts 2
  • Anesthesia planning for delivery (platelet threshold for neuraxial anesthesia, typically >75,000/μL) 2
  • Delivery planning (mode of delivery should be based on obstetric indications, not platelet count) 1, 2
  • Potential treatments that may be needed (corticosteroids, IVIG) 1, 2
  • Neonatal monitoring plan (cord blood platelet count, transcranial ultrasound if platelets <50,000/μL) 1
• Note any planned follow-up with obstetrics team 2

Important Considerations

• The trend of platelet counts is as important as absolute values; rapidly falling counts require closer monitoring than stable low counts 1
• For patients with platelet counts >75,000/μL, neuraxial anesthesia is generally considered safe 2
• Mode of delivery should be determined by obstetric indications only, not maternal platelet count 1, 2
• Fetal/neonatal platelet count cannot be reliably predicted from maternal values 1
• Avoid procedures during labor that increase hemorrhagic risk to the fetus (fetal scalp electrodes, scalp blood sampling, ventouse delivery) 1