How should low platelet counts be managed during pregnancy?
Q: I am 36 weeks pregnant. I have gestational diabetes and taking insulin doses as 4-6-15 units with 1800 calorie diabetic diet. My platelet count was low (approximately 1 million) a month before. From last month, it is further going low to 60,000 - 70,000. I have nose bleeding every other day. I occasionally feel tired and dizzy also. I am taking Ferrium XT (100 mg) daily. My doctor says that platelet transfusion will be given during labour, if required. What food should I take, which will increase the platelet counts? Is the count of 60,000 or below serious?
A:Thrombocytopaenia (or low platelet count) seen in pregnancy is usually caused by ‘gestational thrombocytopaenia’ (GT), a benign self-limiting state with no significant bleeding-risk to mother or baby. But it is difficult or impossible to distinguish this condition from idiopathic (autoimmune) thrombocytopaenia (ITP), in which antibodies develop against one’s own platelets. These antibodies can cross the placenta and have the potential to cause bleeding in the newborn (fetal or neonatal thrombocytopaenia and haemorrhage). Low platelet count in a mother may also be due to some complication of pregnancy like pre-eclampsia or disseminated intravascular coagulation (DIC) or secondary to some underlying disease. Thus, women with thrombocytopaenia during pregnancy should be examined and tested to exclude: Pre-eclampsia; Disseminated intravascular coagulation; Haemolytic uraemic syndrome / thrombotic thrombocytopaenic purpura; Autoimmune thrombocytopaenia – idiopathic / drug-related / SLE / antiphospholipid syndrome / infection-related; Folate deficiency; Coincidental marrow disease and Hypersplenism. Platelet count usually falls as pregnancy progresses, the lowest levels being during the third trimester. Current guidelines recommend that asymptomatic patients with platelet counts >20,000/ml do not require treatment until delivery. Platelet counts of more than 50,000/ml (with normal coagulation profile) are safe for normal vaginal delivery as also a Caesarean section but preclude the use of epidural anaesthesia for which the platelet count should be > 80,000/ml. The treatment is by corticosteroids or intravenous gammaglobulins (IVIg). Steroids are used if the duration of treatment is likely to be short, i.e. starting in the third trimester but if steroid therapy is likely to be prolonged or very high maintenance dose is required, significant side effects may occur and IVIg therapy should be considered. If there is no response to oral steroids or IVIg, high dose intravenous methyl prednisolone alone or in combination with IVIg or treatment with azathioprine is indicated. The risk of clinically dangerous thrombocytopaenia in the newborn is very low but cannot be predicted by clinical or laboratory parameters in the mother. Platelet infusion is a temporary measure, which should be administered for life-threatening haemorrhage and should be available prior to surgery for patients with severe thrombocytopaenia. A platelet transfusion alone is of no use as the transfused platelets would be destroyed. There is no diet that affects platelet count. Continue to take iron and folic acid.