Management of immune thrombocytopenic purpura in pregnancy

Chronic immune thrombocytopenic purpura (ITP) is an autoimmune disease characterized by a low platelet count and mucocutaneous bleeding. Pregnancy does not increase the incidence of ITP nor does it exacerbate a preexisting disease. Although pregnant women with ITP may experience several maternal and fetal complications, in most cases even with a very low platelet count, there is neither maternal nor fetal morbidity or mortality. Corticosteroids are the first line of therapy in pregnant women; intravenous immune globulin is commonly used in steroid resistant patients. Other treatments such as intravenously administered anti-D (Rhogam) and splenectomy during pregnancy have been reported. Antiplatelet IgG antibodies can cross the placenta and can induce fetal thrombocytopenia. In most women there is no indication to assess fetal platelet counts during the pregnancy. The mode of delivery is determined by obstetrical considerations.     

Drugs in pregnancy. Drugs for obstetric conditions.

For many reasons, including the fear of fetal anomaly, the recognition of pregnancy being a normal physiological process and maternal choice, few drugs are prescribed and used during pregnancy. Nevertheless, there are certain common obstetric conditions that are associated with significant maternal and perinatal morbidity and mortality where drugs play an important and necessary part in treatment. These conditions include termination of pregnancy, threatened preterm labour, induction of labour and post-partum haemorrhage. This chapter deals with the role of drug therapy in these obstetric scenarios. A large amount of obstetric clinical trial research has been dedicated to the management of these conditions.     

Drugs for obstetric conditions

For many reasons, including the fear of fetal anomaly, the recognition of pregnancy being a normal physiological process and maternal choice, few drugs are prescribed and used during pregnancy. Nevertheless, there are certain common obstetric conditions that are associated with significant maternal and perinatal morbidity and mortality where drugs play an important and necessary part in treatment. These conditions include termination of pregnancy, threatened preterm labour, induction of labour and post-partum haemorrhage. This chapter deals with the role of drug therapy in these obstetric scenarios. A large amount of obstetric clinical trial research has been dedicated to the management of these conditions.     

Pregnancy complicated with autoimmune diseases

Autoimmune disorders such as SLE and ITP occur more commonly in young women and are the most common complications in pregnancy. There is considerable controversy concerning the risk to the mother and fetus, and the optimal prepartum management for minimizing that risk. 1. SLE is an autoimmune disorder in which IgG antibodies such as anti dsDNA-IgG, anticardiolipin IgG, and anti SS-A/Ro IgG are produced. Lupus nephropathy accompanied by diminished serum complement (CH50) and a rise in antibodies against dsDNA is a frequent clinical problem during pregnancy, which represents the adverse effect of hypertension or superimposed toxemia and causes fetal death or intrauterine fetal growth retardation. Habitual abortion or fetal death is common in a case with high anticardiolipin IgG titre. Anti SS-A antibodies are often found in the infants of antibody-positive mothers, and the deposition of antibodies in the perinodal region cause congenital heart block. IgG or immune complexes crossing the placenta directly injures the cardiac conduction system. In these cases which have high titre crossing the placenta directly injuries the cardiac conduction system. In these cases which have high titre of autoimmune antibodies, corticosteroid therapy should be started. 2. Management of ITP in pregnancy involves the consideration of three issues: 1) treatment of maternal thrombocytopenia, 2) prediction of fetal thrombocytopenia, 3) obstetrical management. ITP increases the risk for postpartum bleeding of sufficient severity to require blood transfusion. In most of these cases, maternal platelet counts are found to be less than 30,000/mm3. Women who have symptomatic severe steroid-unresponsive ITP may benefit from intravenous IgG(IvIgG) given as elective treatment.(ABSTRACT TRUNCATED AT 250 WORDS)     

Prenatal diagnosis and management of bleeding disorders with fetal blood sampling

The technique of fetal blood sampling for prenatal diagnosis has been shown to be both feasible and safe. The availability of fetal blood for direct evaluation has changed our attitude about the problems of both hereditary and acquired immune fetal bleeding disorders. We can continue with the classic approach and use fetal blood sampling for those conditions in which termination may be recommended, but we can also investigate less severe disorders in which the diagnosis allows us to plan the management of the pregnancy and minimize intrapartum and neonatal complications. We report our experience in prenatal diagnosis and management of 103 cases of hereditary and 18 cases of acquired immune bleeding disorders. We have developed specific management plans depending on the disorder under investigation, the severity of the condition in the fetus, and parental wishes. We have performed in utero transfusions of platelets and factor concentrate where appropriate. Efficacy of maternal therapy for fetal conditions can be directly assessed during gestation. Mode of delivery is determined by obstetric conditions and fetal status, directly assessed after appropriate therapy. Closer surveillance of the fetus by fetal blood sampling gives precise information on which to base clinical decisions to provide optimal maternal and fetal outcome.     

Preterm premature rupture of the membranes: diagnosis and management

Preterm premature rupture of the membranes (preterm PROM) is a common and significant cause of preterm birth and perinatal morbidity and mortality. The obstetric caregiver has the opportunity significantly to alter pregnancy and perinatal outcome for women suffering from this complication. Although management is often predetermined by the presence of clinical infection, vaginal bleeding, labor, or nonreassuring fetal heart-rate pattern on admission, a gestational age-based approach to the management of the stable patient with preterm PROM offers the potential to reduce perinatal infectious and gestational age-dependent morbidity for patients who are amenable to conservative management.     

Doppler flow velocity waveform analysis in high risk pregnancies: a randomized controlled trial.

OBJECTIVE--To test whether the introduction of Doppler waveform analysis into the ultrasound department of a tertiary level hospital reduces neonatal morbidity and improves obstetric management. DESIGN--A randomized controlled trial. SETTING--Department of Ultrasound, King Edward Memorial Hospital, Perth, Western Australia. SUBJECTS--505 women with pregnancy abnormalities referred to an ultrasound department for fetal investigation during the third trimester. INTERVENTION--Continuous wave Doppler studies of umbilical and uteroplacental arterial circulations. Results were revealed to patients and clinicians. MAIN OUTCOME MEASURES--Principal end point was the duration of neonatal stay in hospital; other end points included the number and type of fetal heart rate monitoring studies, obstetric interventions, frequency of fetal distress, birthweight, Apgar scores and need for neonatal intensive care. RESULTS--There was no effect on the duration of neonatal stay in hospital. Small trends in obstetric management were observed with study group patients having fewer contraction stress tests, less likelihood of antepartum fetal distress, and more likelihood of fetal distress after induction of labour leading to emergency caesarean section. Depressed Apgar scores were more frequent in the study group. CONCLUSION--Introduction of Doppler waveform studies did not result in reduced neonatal morbidity but did have a small effect on obstetric management. For each institution the role of Doppler studies in late pregnancy will be influenced by the usage of other tests of fetal welfare already entrenched in clinical practice.     

Fetal subependymal cysts with normal neonatal outcome. A case report

The authors report the prenatal sonographic diagnosis of subependymal cysts, confirmed by in utero MRI, in an apparently uneventful pregnancy. The sonographic appearance of the lesions, the obstetric management and the postnatal follow-up to one year are described. Special attention is paid to prenatal factors of neurological morbidity, rather than intrapartum and postnatal, thus emphasizing the importance of early and sequential evaluation of the developing fetal brain. Diagnosis, clinical significance and outcome of prenatal subependymal cysts are necessary for parental counselling and obstetric management. Furthermore, the detection of a prenatal brain injury may have remarkable medico-legal implications.     

Evans’ syndrome in pregnancy: A systematic literature review and two new cases

Evans’ syndrome, the coexistence of immune thrombocytopenia (ITP) with autoimmune haemolytic anaemia (AIHA), is rare in pregnancy, with a few published cases. Concerns about the teratogenic effect of pharmacological agents used in the management of Evans’ syndrome limit the treatment options in pregnancy. In this paper we performed a systematic review of the literature of all published cases with Evans’ syndrome in pregnancy and we report two new cases. The review was performed by searching the electronic databases PubMed, EMBASE, Cochrane Library and Google scholar up to the end of December 2008. The selection criteria were Evans’ syndrome in pregnancy; autoimmune haemolytic anaemia; immune thrombocytopenia. Thirteen papers reporting 14 pregnancies in women with Evans’ syndrome have been published: 7 papers are written in English. Evans’ syndrome can be diagnosed with a full blood count, film and Coombs testing. It runs a more benign course in pregnancy than in non-pregnant state (notably neutropenia does not occur) and very often resolves post-delivery. The fetal outcome may be less favourable: a minority of fetuses are affected by transplacental passage of antibody and have a significant morbidity and mortality. With appropriate treatment, women with Evans’ syndrome can have successful pregnancies, with a good response to conventional treatment. More detailed studies of Evans’ syndrome in pregnancy, especially of fetal outcome, are required.     

Management of idiopathic thrombocytopenic purpura during pregnancy.

Management of idiopathic thrombocytopenic purpura (ITP) during pregnancy requires concern for both fetal and maternal morbidity and death. A review of 14 pregnancies revealed significant maternal morbidity but no maternal deaths. The perinatal mortally was21 per cent. Current recommendations for management include: (1) corticosteroids, (2) splenectomy if response is unsatisfactory with (1), (3) liberal use of platelet transfusion if surgical intervention is required in the face of significant thrombocytopenia, and (4) careful observation of the newborn infant and treatment with corticosteroids and/or platelets if thrombacytopenia is severe.     

Obesity and diabetes: A recipe for obstetric complications

The prevalence of obesity has been increasing worldwide and has reached epidemic proportions in the United States, where well over 20% of the population have a body mass index (BMI) within the obese range. Obesity is associated with a wide spectrum of obstetric and perinatal complications, including increased risks of fetal mortality and morbidity, congenital malformations, maternal hypertensive disorders, gestational diabetes, excessive fetal growth and cesarean delivery. The odds ratios for these risks increase in direct correlation with the severity of obesity, and are significant even among women who are overweight without meeting criteria for obesity. Although obesity is closely associated with diabetes which, in itself, is associated with similar perinatal complications, diabetes and obesity are independent risk factors for adverse pregnancy outcome. Moreover, improving glycemic control in the pregnant woman with diabetes may mitigate the additive adverse effects of diabetes and obesity on pregnancy outcome.     

Obesity and diabetes: A recipe for obstetric complications.

The prevalence of obesity has been increasing worldwide and has reached epidemic proportions in the United States, where well over 20% of the population have a body mass index (BMI) within the obese range. Obesity is associated with a wide spectrum of obstetric and perinatal complications, including increased risks of fetal mortality and morbidity, congenital malformations, maternal hypertensive disorders, gestational diabetes, excessive fetal growth and cesarean delivery. The odds ratios for these risks increase in direct correlation with the severity of obesity, and are significant even among women who are overweight without meeting criteria for obesity. Although obesity is closely associated with diabetes which, in itself, is associated with similar perinatal complications, diabetes and obesity are independent risk factors for adverse pregnancy outcome. Moreover, improving glycemic control in the pregnant woman with diabetes may mitigate the additive adverse effects of diabetes and obesity on pregnancy outcome.     

The influence of obstetric practices on late prematurity

In this article, the authors review the standard management of several maternal and fetal complications of pregnancy and examine the effect these practices may have on the late preterm birth rate. Given the increasing rate of late preterm birth and the increased recognition of the morbidity and mortality associated with delivery between 34 and 37 weeks, standard obstetric practices and practice patterns leading to late preterm birth should be critically evaluated. The possibility of expectant management of some pregnancy complications in the late preterm period should be investigated. Furthermore, prospective research is warranted to investigate the role of antenatal corticosteroids beyond 34 weeks.     

Epilepsy and Pregnancy

A retrospective study of 75 pregnant epileptic women compared with a parity, age and socioeconomic matched control group of women is presented. Deterioration of control of epilepsy during pregnancy occurred in 24% of women. Statistically significant obstetric complications noted were anaemia, premature labour, premature rupture of the membranes and postpartum haemorrhage. There was 2.5-fold increase in the incidence of congenital anomalies in the neonates, an increase in feeding difficulties and a reduced incidence of jaundice. There was no maternal or perinatal death. Refinements in management may further reduce the maternal and fetal morbidity in epileptic women who choose to become pregnant.     

Postnatal morbidity after childbirth and severe obstetric morbidity

Objective To identify the impact of pregnancy and childbirth, and severe obstetric morbidity on outcome 6 to 12 months postpartum.
Design Questionnaire assessment of postnatal outcome in a cohort study.
Setting South East Thames, UK.
Population All women resident in South East Thames and delivering between 1st March 1997 and 28th February 1998.
Methods Questionnaire study of a cohort of women who experienced a severe obstetric morbidity during pregnancy or labour (cases), compared with a cohort of women who did not (controls).
Main outcome measures Assessment of postnatal depression risk [Edinburgh Postnatal Depression Scale (EPDS)], general health [Short Form 36 (SF-36)], sexual activity and use of health services between 6 and 12 months postpartum.
Results There were 331 cases and 1339 controls out of 48,262 deliveries. Six to 12 months after delivery, 77 (23.3%) of cases and 272 (20.5%) of the controls were at risk of postnatal depression (   P = 0.25; 95% CI for difference −2.2% to 7.9%  ), 43.1% of cases were having problems with sexual relations compared with 18.7% of controls (   P < 0.001; 95% CI for difference 8.9% to 21.9%  ). There was evidence of poorer general health in cases. Some 31.5% of cases attended outpatients in the first six months and 9.4% required emergency admission to hospital compared with 17.0% (   P < 0.001; 95% CI for difference 9.1% to 19.9%  ) and 3.7% (   P < 0.001; 95% CI for difference 2.4% to 9.0%  ), respectively, in controls.
Conclusion Both control pregnancy and childbirth and severe obstetric morbidity are associated with significant postnatal morbidity. A severe obstetric morbid event significantly influences women's sexual health and wellbeing and increases health services utilisation. Prevention and appropriate management of severe obstetric morbid events may reduce these outcomes.     

Mycotic aneurysms in pregnancy

The presentation, management, and outcome of three cases of femoral artery mycotic aneurysm in pregnancy are described. All resulted from illicit intravenous drug use. While the literature dealing with drug abuse in pregnancy is large, this specific problem has received little attention. Comparison of these cases to a large reported series of nonpregnant patients with mycotic aneurysms from our institution demonstrates that pregnancy does not alter the natural course of this condition. The presence of a mycotic aneurysm in pregnancy does, however, appear to lead to significant maternal and fetal morbidity.     

Vasa praevia: a lethal threat to the fetus

Vasa praevia constitutes a rare obstetric complication that is potentially lethal for the generally healthy infant. If unrecognized antenatally, the condition carries a higher fetal mortality rate than any other complication in pregnancy. Only in the past two decades have major diagnostic advances led to a dramatic improvement of perinatal survival and lower morbidity rates. Good outcomes depend primarily on prenatal diagnosis and appropriate management. The performance of a caesarean section before rupture of the membranes and the onset of labour is mandatory. Simple modifications of standard screening protocols and the recognition of high-risk patients will allow identification of most cases of vasa praevia.     

Placement of a vena cava filter in term pregnancy: case report and review of the literature

During pregnancy there are hemostatic changes that may result in a hypercoagulable state producing thrombotic consequences. This condition may be aggravated in women who are carriers of congenital thrombophilic factors. These factors may increase obstetric complications such as miscarriages, fetal growth restriction, placental abruption and preeclampsia. Trombophilic factors may also cause venous thromboembolism, which is the leading cause of maternal morbidity and mortality. We report a case of a 22-year-old woman with factor V Leiden mutation, whose pregnancy was complicated with deep venous thrombosis requiring placement of a vena cava filter.     

Shoulder dystocia

Shoulder dystocia is an uncommon but not rare obstetric emergency. Death of the infant is unusual but perinatal morbidity is frequent and can result in permanent injury. These cases carry significant medico-legal implications. This chapter covers the mechanisms, predisposing factors and management of shoulder dystocia. A well-rehearsed sequence of manoeuvres to manage shoulder dystocia will minimize fetal trauma.     

Connective tissue and dermatological disorders in pregnancy

Connective tissue disorders, particularly those that are autoimmune, are being seen with increasing frequency in the pregnant population. The care of these patients in pregnancy ranges from the routine to the complicated, with some of the conditions posing significant risks both to the mother and the fetus. Dermatological conditions are often encountered in pregnancy, and again range from the benign to those resulting in serious fetal and maternal morbidity, with a number being specific to pregnancy. An important issue for both groups of disorders is the use of particular medications during pregnancy. Those with pre-existing disease should ideally be counselled pre-pregnancy to optimize treatment and adjust medication as appropriate. During pregnancy, frequency of review and degree of treatment will depend on the severity of the condition, and may require multidisciplinary team involvement to optimize both maternal and fetal outcome, including obstetric physicians, obstetricians, anaesthetists, neonatologists, and geneticists.