What is the most appropriate management for a 30-year-old woman, gravida (number of times pregnant) 1, para (number of viable births) 0, at 29 weeks gestation, presenting with increasing fatigue, shortness of breath on exertion, and bilateral leg swelling, with a hemoglobin level of 11.2 g/dL, thrombocytopenia (low platelet count), and 2+ pitting edema?

From the Guidelines

The most appropriate management for this patient is close monitoring with weekly prenatal visits, focusing on blood pressure measurements, assessment of proteinuria, complete blood counts to monitor platelet trends, and liver function tests, as her moderate thrombocytopenia and symptoms could be indicative of an underlying condition such as gestational thrombocytopenia or a precursor to preeclampsia or HELLP syndrome 1. This 30-year-old woman at 29 weeks gestation is presenting with symptoms that are largely consistent with normal pregnancy changes, including fatigue, exertional dyspnea, and lower extremity edema. Her vital signs are within normal limits, and her fundal height corresponds appropriately with her gestational age.

• While her hemoglobin has slightly decreased from 11.8 g/dL to 11.2 g/dL, this is within the expected physiologic hemodilution of pregnancy.
• The most concerning finding is her platelet count, which has decreased from 240,000/mm³ to 118,000/mm³. This moderate thrombocytopenia warrants close monitoring but does not require immediate intervention at this time, as gestational thrombocytopenia affects 5-10% of pregnancies and is typically benign, but the patient should be monitored for development of preeclampsia, HELLP syndrome, or other pregnancy complications 1. Weekly visits should include:
• Blood pressure measurements
• Assessment of proteinuria
• Complete blood counts to monitor platelet trends
• Liver function tests The patient should be educated about warning signs that would necessitate immediate evaluation, including severe headache, visual changes, right upper quadrant pain, or decreased fetal movement. If her platelet count continues to decline or if she develops other concerning symptoms, more aggressive management may be needed, potentially including the consideration of platelet transfusion based on guidelines such as those from the AABB for patients with therapy-induced hypoproliferative thrombocytopenia 1.

From the Research

Patient Presentation and Laboratory Results

The patient is a 30-year-old woman, gravida 1 para 0, at 29 weeks gestation, presenting with increasing fatigue, shortness of breath with exertion, and bilateral leg swelling. Her initial prenatal visit was at 10 weeks gestation, with a complete blood count showing hemoglobin of 11.8 g/dL, platelets of 240,000/mm3, and leukocytes of 8,000/mm3. Today, her blood pressure is 124/84 mm Hg, pulse is 77/min, and respirations are 22/min, with a cardiac examination that is normal and lungs clear to auscultation bilaterally. Fundal height is 29 cm, and fetal heart rate is 160/min, with bilateral lower extremities having 2+ pitting edema up to the knees. A complete blood count today shows hemoglobin of 11.2 g/dL, platelets of 118,000/mm3, and leukocytes of 8,200/mm3.

Differential Diagnosis and Management

• The patient's low platelet count (thrombocytopenia) is a concern, and the cause needs to be determined for appropriate management.
• Possible causes of thrombocytopenia in pregnancy include gestational thrombocytopenia, immune thrombocytopenic purpura (ITP), and heparin-induced thrombocytopenia (HIT) 2.
• The patient's symptoms and laboratory results do not suggest HIT or ITP, but rather gestational thrombocytopenia or another cause of thrombocytopenia.
• Management of thrombocytopenia in pregnancy depends on the underlying cause and severity of the condition.
• For gestational thrombocytopenia, treatment is usually not necessary, but close monitoring of the patient's platelet count and fetal well-being is recommended.
• For ITP, treatment options include corticosteroids, intravenous immunoglobulin (IVIG), and platelet transfusions 3, 4.
• In cases of severe thrombocytopenia, IVIG and platelet transfusions may be necessary to prevent maternal and fetal complications 5, 3.

Considerations for Fetal Well-being

• The patient's fetal heart rate is normal, and there are no signs of fetal distress.
• However, the patient's thrombocytopenia and symptoms of fatigue and shortness of breath may affect fetal well-being.
• Close monitoring of fetal movement and well-being is recommended, and antenatal corticosteroids may be considered to promote fetal lung maturity if preterm delivery is anticipated 6.