What is the evaluation and management plan in SOAP (Subjective, Objective, Assessment, Plan) format for an obstetric patient with thrombocytopenia prior to referral to Internal Medicine Hematology (IM HEMA)?

Evaluation and Management of Obstetric Patients with Thrombocytopenia for IM HEMA Referral: SOAP Format

Subjective

• Document any bleeding symptoms including bruising, petechiae, and menorrhagia 1
• Record comprehensive medical history:
  • Previous history of thrombocytopenia (especially when not pregnant) 2
  • Medication history (including any drugs that could cause thrombocytopenia) 1
  • Family history of thrombocytopenia or bleeding disorders 1
  • Current pregnancy details and gestational age 1
  • Previous pregnancy outcomes and complications 3

Objective

• Complete blood count with platelet trends over time is essential to distinguish between gestational thrombocytopenia and ITP 1, 3
• Coagulation studies:
  • PT/INR, aPTT, fibrinogen 1
  • These must be normal to consider regional anesthesia 2
• Tests to rule out secondary causes:
  • HIV, HCV, H. pylori (if clinically indicated) 1, 2
  • Liver function tests to rule out HELLP syndrome 2
  • ANA and antiphospholipid antibodies to rule out autoimmune conditions 2
• Peripheral blood smear to exclude pseudothrombocytopenia and evaluate platelet morphology 4

Assessment

• Differentiate between causes of thrombocytopenia in pregnancy:

  • Gestational thrombocytopenia: Most common (75% of cases), mild (usually >70,000/μL), occurs in late gestation, resolves after delivery 2
  • ITP: Pre-existing or new onset, can be more severe, may not resolve after delivery 2
  • Preeclampsia/HELLP syndrome: Associated with hypertension and other systemic findings 5
  • Other causes: Drug-induced, infectious, or hereditary thrombocytopenia 4

• Risk assessment:

  • Maternal bleeding risk: Significant if platelets <20,000-30,000/μL 2
  • Anesthesia considerations: Regional anesthesia generally safe if platelets >75,000/μL 2, 3
  • Fetal/neonatal risk: Cannot be predicted by maternal platelet count 2, 3

Plan

Monitoring

• Regular platelet count monitoring with increased frequency as delivery approaches 3
• Monitor trend of platelet counts - a rapidly falling count requires closer observation than stable low counts 2

Treatment

• For platelets >30,000/μL without bleeding: Observation only if stable 2
• For platelets <20,000-30,000/μL or symptomatic bleeding:
  • First-line: Corticosteroids (prednisone) or IVIg 2, 3
  • Consider treatment to increase platelet count before delivery or procedures 3

Delivery Planning

• Mode of delivery should be determined by obstetric indications only, not by maternal platelet count 2, 3
• Avoid procedures with increased hemorrhagic risk to fetus:
  • Fetal scalp electrodes
  • Fetal blood samples
  • Ventouse delivery
  • Rotational forceps 2

Anesthesia Planning

• Consult anesthesiology early in third trimester 2
• For regional anesthesia:
  • Generally safe if platelets >75,000/μL 3
  • For platelets 50,000-75,000/μL: Individual risk-benefit assessment 2
  • Spinal may be safer than epidural due to smaller needle size 2

Neonatal Planning

• Cord blood platelet count at delivery 2
• Avoid intramuscular injections in newborn until platelet count is known 2
• Transcranial ultrasound for neonates with platelets <50,000/μL 2, 3
• Treatment plan for thrombocytopenic newborn if needed (IVIg, platelet transfusion) 2

IM HEMA Referral Information

• Include all of the above information in your referral to IM HEMA, with special emphasis on:
  • Complete platelet trend data 1
  • Timing of thrombocytopenia onset (pre-pregnancy vs. during pregnancy) 2
  • Results of all completed workup 1
  • Current gestational age and delivery plans 1, 3
  • Any bleeding symptoms 1