ļ»æEpisode 27 - Low Platelets in pregnancy (Gestational Thrombocytopaenia)
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host,
[0:03] Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD. And each episode, I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey.
[0:23] Hello rebels this is episode 27 of the great birth rebellion and i'm melanie jackson we've had a little bit of a hiccup this week just life happens and b and i had planned to record together and then i got sick and so i couldn't record but now i'm better and b can't record because of course her week is well and truly already planned so in order to get you an episode today I've sat down to record this episode myself without Bea just as a rescue mission to make sure that we deliver we want to deliver rebellious content and so this is our compromise life happens we've got kids we've got bodies that don't always work the way we want them to work and that's what happened this week so in the email that you would have gotten out if you are on the mailing list well we, send out an email once a week to tell you what's coming up next week and I told you that it was going to be on small babies big babies and there's going to be a two-part episode series.
[1:32] On big babies small babies which is what we were planning but I'm not going to do that because I to do that with B.
[1:39] So instead of big babies, small babies or small babies, big babies. Today, I want to talk to you about something that I've been heavily researching because I've been working through it with one of my clients recently. And so I feel really up to date with the research. And actually it also links in really, really well with the questions that we were getting after the postpartum hemorrhage episode and the placental birth episode. And so this episode is about gestational thrombocytopenia. I know, massive words, but we're going to talk all about it. And so that's where we're up to. That's why I'm filling you in on all the details is that if you were expecting an episode on big babies, small babies, I apologize, it's coming and it will be with Bea and I. But today you get to enjoy my very illustrious, if that's the word, voice, post-sick voice. While I talk to you all about the very sexy topic of gestational thrombocytopenia.
[2:38] So here we go, rebels. Let's get into it. All right. So the reason I'm talking about this is we got a lot of questions after the PPH episode about this because quite a number of women are diagnosed with gestational thrombocytopenia or what we're going to talk about as being low platelets in pregnancy.
[2:59] And the research on this suggests that somewhere between 10 and 15% of pregnant women will be diagnosed with low platelets during pregnancy. So it's a decent number and a really good understanding of why we got all of those questions after the PPH episode, because it affects so many women. And the reason I want to talk about it is that it's not just considered a benign, don't worry about it kind of thing or finding that doctors find and then just do nothing about.
[3:31] Sometimes you will be encouraged to have an induction or some kind of treatment as a result of being diagnosed with low platelets in pregnancy. So I want to break this down and talk about when induction or intervention is appropriate and when it might not be necessary. So let's get started.
[3:53] Thrombocytopenia or low platelets in pregnancy is defined as less. So this is the other confusing thing is that they measure it in number times 10 to the power of nine. So anyway, I'm just going to talk about it in a broad number. So platelets less than 150 is defined as thrombocytopenia. And a lot of the papers talk about it as affecting between 10 and 15% of pregnancies.
[4:24] So as I said before, gestational thrombocytopenia is a fancy word for low blood platelet levels in pregnancy. So from here on in, I'm just going to say low platelets instead of gestational thrombocytopenia. But so when I say low platelets, you know what I'm talking about. Platelets are one part of your blood circulating blood volume. So it's one a component of your blood and it's part of the mechanism by which how your blood clots and there are there is a natural reduction in platelets during pregnancy we know that platelets actually naturally will get lower in pregnancy but there are other factors in our bodies that contribute to your clotting abilities and what we know about that is that they actually become heightened in women's pregnancies. So there's an increased action and sensitivity in other clotting factors, even though the number of platelets naturally reduces. So women actually have a greater capacity for blood clotting during pregnancy. And, you know, theoretically, they say it could be considered a protective mechanism for postpartum blood loss.
[5:37] That's kind of naturally what's happening. And I won't go into all of the details about how that occurs. But if you are on the mailing list for this podcast, then you'll see a great number of research papers in the resource folder for this episode. And it gives you a rundown and shows you all the chemical factors behind how women clot their blood during pregnancy and postpartum and why platelet levels aren't necessarily the biggest issue when it comes to considering if low platelets leads to an increased risk of bleeding. So you can have a look at that mechanism and all the science of it if that's what you're into in the resource folder you'll see all the papers for that. Side note if you want to be on the mailing list and get access to the resource folders for this podcast, just go to melanethemidwife.com and you can sign up to the podcast mailing list and you'll see the resources for all of this podcast and all previous episodes. So you won't miss out on a thing.
[6:39] So back to it. So gestational thrombocytopenia or low platelets is essentially low platelet levels during pregnancy and the current guidelines suggest that below 150 is considered low. I'm doing inverted commas low and you'll realize why I'm doing inverted commas as we get through this because spoiler alert it's completely bogus but there are some diseases and pathological processes that can cause thrombocytopenia. And there are some very severe ones. So I want to put a caveat in here. I'm talking about gestational thrombocytopenia that has no pathological cause. Just it's happening. There's no actual illness or disease going on. It's just an isolated incident in your pregnancy. So things like preeclampsia and HELP syndrome can cause platelets to drop significantly and if that's you.
[7:46] If that's what's happening for you and that's why your platelets are dropping, I would encourage you to accept all the medical help that's offered to you. This is a fast-moving and severe circumstance and it can't be fixed without medical intervention. Having said that, we aren't going into pathological reasons for low platelets today. This is just about low platelets occurring in isolation, not related to a disease process. So everything is normal. You just have low platelets. So please don't apply this research to a circumstance where you actually have a disease or a pathological reason for why your platelets are low.
[8:24] All right, so big problem already here is the definition of low platelets or
[8:29] gestational thrombocytopenia. So the definition states that lower than 150 classifies a woman as having low platelets.
[8:38] So many hospitals will use this cutoff, the 150 cutoff, as classifying women into a category of low platelets or gestational thrombocytopenia. Red flags go up. but as always let's have a look at the research on this limit on this 150 limit now as I said I'm feeling very confident on my line of thought for this one because recently I worked through and researched a whole buttload of stuff for my clinical care around gestational thrombocytopenia for a client of mine who had platelets of 80 and she wanted to give birth at home so we explored every avenue to understand the risks of her circumstance and make a plan for her birth and before anybody goes and reports me to APRA or the HCCC take your shoes off she had an obstetrician as part of her care and we followed all the guidelines for her care okay so pens down no need for alarm everything was fine she had her baby she did not bleed to death everyone involved including the hospital was happy and the woman was happy and safe. So okay no need to report me for looking after clients who have low platelets. All right so first up I'm just going to say that this 150 cut off is not based on any evidence whatsoever that I could find.
[10:03] It's an unrealistic standard to set and it puts women into who are it puts women who are not high risk into a risk category that they do not belong to. It pathologizes a completely normal circumstance and brings it under the jurisdiction of medical management.
[10:22] Low platelets are often used as a reason to induce labor early and so understanding the actual risks are important before you choose to take up a risky option like induction if you don't absolutely need to. Induction can be a life-saving and important intervention but it does carry risks and theoretically we should only use something that carries risk if the benefits of that thing outweigh the risks.
[10:52] So what does the actual research say about gestational thrombocytopenia? It accounts for 75% of women presenting with low platelets in pregnancy. So the other 25% are a result of a disease or a pathological process that's pre-existing or that's developing. But 75% is this just low platelets. The majority of these 75% of women have platelet counts that are above 100 and 10% of women with low platelets have platelet counts that are below 100 and it usually develops in the third trimester of your pregnancy and resolves what they call spontaneously after delivery it causes no adverse effects to the baby and the women are asymptomatic. So you can't feel if you've got low platelets.
[11:48] It tends to reoccur in each pregnancy, but in between the pregnancies, the platelet counts are normal. So this is a handy way, you know, that you might be able to yourself feel confident that it's gestational thrombocytopenia, that actually in between pregnancies, your platelets are normal, that means there's not usually a pre-existing issue with your platelets or an underlying pathological process going on. To date, we don't really understand why women get gestational thrombocytopenia, but we do know that it's normal for platelet counts to drop in pregnancy. So it's considered a normal physiological process in pregnancy, but we don't understand the exact reason why it happens.
[12:36] Okay, so I've already told you that this limit of 150 is quite bogus,
[12:41] according to the research. So let's have a look at what it does say. So isolated low platelets, so there's no other pathological process going on, is considered rarely of concern, one research paper said, rarely of concern, especially if counts remain above 100.
[13:01] Management is what we call observational and requires no specific treatment. So that might simply be doing a blood test to check the platelet's levels through the pregnancy.
[13:13] Platelet counts less than 70 that aren't associated with preeclampsia warrant further investigation because rarely in just gestational thrombocytopenia, so isolated low platelets, does it drop below 70. So if it does drop below 70, that might be a red flag that there's actually a pathological process going on and it's more than just this benign low platelets. Okay, so what we know is that the fear that people have about low platelets is that in their mind they're saying, oh, low platelets, that means they're more likely to bleed. That means we should do something, right? But the research doesn't support that. What the research tells us is that patients with low platelets, gestational thrombocytopenia did not experience increased bleeding or need for transfusion compared to a control group. So previous published data suggested that there is an increase but the problem with some of these studies is that they didn't distinguish between gestational thrombocytopenia with no pathological cause and other causes of thrombocytopenia. So there are disease-based causes for low platelets and there are just the normal situation of pregnancy.
[14:36] What's more is that ACOG, the American College of Gynecologists and Obstetricians, I think it's called ACOG, but anyway, you'll see their paper in the research folder. They say that clinically significant bleeding, so that usually means anything over a thousand mils, clinically significant bleeding usually is limited to patients with extremely low platelet levels who are undergoing a major surgical intervention. And certainly my exploration and discussions with anaesthetists and obstetricians is that they tend to agree that platelets below 80 could be an issue, but you can sometimes in some hospitals still have an epidural if your platelets are 50 and women with low platelets are still allowed they will undergo cesarean sections even with platelets between 50 and 80 and surgery is a higher risk of bleeding than vaginal birth so what i'm saying is that the the cutoff of 150 is ridiculous step one that most of you if you have low platelets, your platelets won't drop below 100.
[15:56] And even if they do, the range where there's concern, where, for example, an anaesthetist would not do an epidural for you because there's risk of bleeding into your spinal space, is anything below 80. So if you've been told you've got low platelets, find out what the number is, like how low are my platelets? If they're above 100, the research suggests that you don't have any increased risk of bleeding for your birth. And therefore, you can consider whether or not you'd want to submit to anything like an induction, for example, if your platelets were between 100 and 150.
[16:35] Now, another article that I was reading, I'm going to read it verbatim because it's really nice wording. It says, From a practical standpoint, the current guidelines consider that vaginal delivery or vaginal birth is safe when platelet counts are higher than 30. For operative, vaginal or cesarean delivery, the safe platelet count should be at least 50. The exact platelet number needed to achieve a safe epidural in most guidelines is around 80 because there's theoretical concern over the risk of an epidural. Hematoma with low platelet levels. So that's where the research sits. But what's clinically happening is that women are considered to have low platelets below 150. Well, they're saying we'd still happily, we still consider that vaginal delivery is safe when platelet count is higher than 30. And a cesarean section is safe if platelets are higher than 50.
[17:40] So, I mean, what do you say? I mean, long story short, the cutoff of 150 is stupid and not evidence-based, and it's time to stop frightening women into inductions and medical management for platelets below 150 or even below 100 if it's above 80.
[18:00] Yes, monitoring of levels is important, but be assured that the research suggests that the danger zone is likely to be in that below 80 range not the below 150 to 80 range.
[18:14] And I realize I keep saying the word delivery instead of birth I'm only just doing that because some of the papers say the word delivery and some of the quotes I'm just reading verbatim so I apologize for that I don't really think babies are delivered they're born just if you ever hear me say delivery it's because i'm reading it so anyway back to the point which i think i've already made is that we should stop using 150 as the cutoff to call women gestational thrombocytopenic or tell women they have low platelets because they're below 150 i personally think a more realistic standard would be like below 100 let's say that as a it's even got a safety margin because the actual research says that there's not really an increased risk with anything above 80 so you know we always like to be extra super safe when we're writing policies and giving clinicians advice so if we said below 100 counts as gestational thrombocytopenia I would be way more excited about how much closer that is to the actual evidence than the cutoff of 150 so just put it out there, if anyone's a sting that writes policies or actually gets to make changes in the hospital...
[19:31] Be brave and suggest that your policy on gestational thrombocytopenia should more closely resemble the research, pardon me, that's my cold rearing its head, that your policy should more closely resemble the research by saying that you don't diagnose gestational thrombocytopenia until the woman's platelets are below 100 because her risk of bleeding doesn't increase between that 100 and 150 range. And women, if you've been told that you have low platelets, find out how low. What number are we talking about? Is there a pathological process going on that you need to be considerate of? Or is this basic gestational thrombocytopenia? And then you can make a decision about whether or not you want to interfere with the pregnancy by inducing, for example, or whether or not you're going to just keep an eye on it and continue your pregnancy as usual.
[20:32] That's my little spiel about gestational thrombocytopenia or low platelets and if you want more information I'd encourage you to read the papers in the resource folder for the Great Birth Rebellion podcast and if you're not already on the mailing list you can get on the mailing list at melanethemidwife.com and you'll have access to all the research that I use to make this podcast today. We'll see you next week with hopefully the episodes that I had planned on big babies, small babies, but life happens and we'll do our best. See you then, Rebels. To get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com and to support the work of this podcast, wear the rebellion in the form of clothing and other merch at theGreatBirth Rebellion. com. Follow me, Mel, @MelanietheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
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