Hematologic Changes in Pregnancy

Published on 04/03/2015 by admin

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Chapter 67 Hematologic Changes in Pregnancy

Caroline Cromwell

Table 67-1 Initiation of Treatment in Pregnant Patients With Idiopathic Thrombocytopenic Purpura

Platelet Count	Treatment
<10,000/µL	Platelet transfusion for life-threatening bleeding
10,000-30,000/µL	Consider monitoring in first trimester; treat in second or third trimester
>30,000/µL	Clinically monitor

Figure 67-1 MICROANGIOPATHIC HEMOLYTIC ANEMIA.

Microangiopathic hemolytic anemia in pregnancy, peripheral blood smear (A and B). Evidence of microangiopathy with the formation of schistocytes, fragmented forms and spherocytes, associated with polychromasia and nucleated red blood cells (A and B, detail).

Imatinib Therapy

A 38-year-old woman with a history of chronic phase CML on imatinib therapy for 5 years becomes pregnant. She has had a complete cytogenetic response. She asks what to do about her imatinib therapy.

Imatinib is teratogenic and should not be used during pregnancy. It has been linked to spontaneous abortions and to fetal malformations including skeletal abnormalities, hydrocephalus, and exopthalmos. While there are case reports documenting fetal exposure at various stages of pregnancy without harm, it is not recommended. Case reports suggest that patients who have achieved maximal response to therapy fare better when their treatment is held for pregnancy, opposed to patients who have not achieved best response.

Table 67-2 Hemostatic Changes in Pregnancy

Factor XIII	↑/↓
Protein C, antithrombin	=
Protein S	↓
Factor XI	↓/ =
Factors V, VII, VIII, IX, X, XII	↑
von Willebrand factor, fibrinogen	↑
Tissue plasminogen activator	↓
Prothrombin, D-dimer	↑

Bleeding Associated with Factor XI Deficiency

A 25-year-old female is referred for prolonged PTT discovered during pregnancy. Evaluation reveals severe factor XI deficiency. She has no history of easy bruising or bleeding. She is at 30 weeks’ gestation and is here for evaluation prior to delivery.

Bleeding associated with factor XI deficiency can be quite variable, ranging from no bleeding symptoms to bleeding associated with trauma or surgery. For a patient without a history of bleeding, prophylaxis is not necessary but fresh frozen plasma should be available if needed. Epidural is usually contraindicated in patients with severe factor XI deficiency, and women should be advised to speak with the treating anesthesiologist prior to delivery in order to plan alternative strategies. If consideration for regional block anesthesia is made, it is usually administered with FFP prior and with documentation of normalization of the PTT.

In patients with a bleeding history, FFP should be administered prior to delivery, as well as 2 to 3 days later to reduce the risk of delayed hemorrhage.

Thrombophilia During Pregnancy

A 25-year-old female wishes to become pregnant. Her mother suffered from a PE at the age of 60, underwent thrombophilia evaluation, and was found to be heterozygous for the factor V Leiden mutation. She herself has never suffered thrombotic episode, just recently discontinued her birth control, and was told to see a hematologist before she became pregnant. Her primary care physician tested her for Factor V Leiden and she is heterozygous for the mutation. She is asking if she should be on anticoagulation during her pregnancy.

Every case of thrombophilia during pregnancy needs to be assessed on a case by case basis. Asymptomatic women who harbor thrombophilic conditions, but have never manifested clinical manifestations, do not require anticoagulation. In women with a personal history of thrombosis an inherited thrombophilia, anticoagulation during and in the postpartum setting should be used.

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